ACP Internal Medicine 2011 News for 4-7-11
Internal Medicine 2011 News reports breaking news and events live each day from Internal Medicine 2011 and the American College of Physicians.
- Follow live updates all week long at Internal Medicine 2011
- Download the Internal Medicine 2011 app
- Annals and ACP announce recipients of Junior Investigator Recognition Award
- Session on CAP and HCAP canceled
- Keynote speaker to address 'medicine as practice'
- Cardiology update will help physicians communicate risks, benefits and harms
- Health care technology briefings to be held at ACP's EHR Forum
- ACP Annual Business Meeting to be held Saturday in Room 17
Recognizing, preventing and treating delirium
If you remember only one thing about treating agitation and delirium in the hospital, it should be to avoid benzodiazepines, said Brian Huang, ACP Member, assistant professor of medicine in the division of hospital medicine at the University of California San Diego, during Wednesday’s hospital medicine precourse.
Before you get to that point, however, you’ll have to recognize your patients with delirium—something hospitalists don’t do a great job with, he said.
“Between 15% and 50% of patients have delirium in the hospital, and it’s thought to be more common in the postoperative setting. Yet the condition is unrecognized in 70% of patients,” Dr. Huang said.
Delirium increases a patient’s length of stay by an average of five extra days, and is associated with loss of independence, increased mortality and worse physical and cognitive recovery, he said.
Clinical features and risk factors
Clinical features of delirium include disturbances of consciousness, arousal and awareness; attention, perceptual and cognitive disturbances; disorientation; disorganized thinking; delusions; psychomotor disturbances; sleep-wake cycle disturbances; and acute onset, Dr. Huang said.
“A nurse or family member can help inform as to whether what you are observing is baseline behavior, or there has been a shift,” Dr. Huang said.
Patient risk factors for delirium include being older than 65 years, having dementia, having functional dependence or immobility, having multiple comorbidities, taking multiple medications, having visual or hearing impairment, and having chronic renal disease. High-risk situations for delirium include dehydration, infection at hospital admission, electrolyte abnormalities, hypoxia, hypoglycemia, neurologic disorder and untreated pain, he said.
There are risks inherent in the hospital environment, as well. These include excessive noise, interrupted sleep, unnecessary stimuli, and having a urinary catheter and physical restraints, Dr. Huang noted. “This is where having an interdisciplinary team comes into play that can help to minimize some of these risk factors,” he noted.
Physicians should also pay attention to the medications a patient is on, as some carry a higher risk of delirium, including anticholinergics, antidepressants, opiates, steroids, benzodiazepines, anticonvulsants and insomnia medications, he said.
When a patient comes in with delirium, the first steps are to rule out other medical causes, review medications, and—in the case of hypoactive delirium—differentiate it from depression, Dr. Huang said.
“The key differences between hypoactive delirium and depression are that, with the latter, patients are drowsy and hypoaroused, while they have a normal level of arousal with depression. Hypoactive delirium also has an abrupt onset, while depression is more gradual and chronic,” he noted.
The Confusion Assessment Method (CAM) is the most commonly used instrument in the literature to assess delirium, he noted. It requires that patients have an acute change and fluctuation in mental status compared to their baseline, and difficulty in focusing their attention. In addition to these two, patients also must have either disorganized thinking (“a rambling, incoherent, illogical flow of ideas”) or an altered level of consciousness (“anything other than alert”).
Hospital staff can take a number of actions to help prevent delirium in those at risk, Dr. Huang noted. These include removing physical restraints and encouraging early mobilization for patients with immobility; providing orienting communication to those with cognitive impairment; using visual aids for those with visual impairments; using hearing aids and adaptive equipment for those with hearing impairment; preventing and correcting dehydration; and providing uninterrupted sleep to those with sleep deprivation.
“For the sleep component, you can avoid checking vitals in the middle of the night, and reschedule procedures so they don’t interrupt early morning sleep,” Dr. Huang noted.
Patients who were subject to these steps, created as part of the Yale Hospital Elder Life Program (HELP), had a 10% incidence of delirium compared to a 15% incidence in a control group, according to a 1999 study published in the New England Journal of Medicine, Dr. Huang said. In the study of 852 elderly patients, the steps were enacted by an interdisciplinary team that included a geriatric RN specialist, trained Elder Life specialists, a therapeutic-recreation specialist, a physical therapy consultant, a therapeutic-recreation specialist, a geriatrician and trained volunteers.
“Even the 15% rate in the nonintervention group was low, so it’s possible there was some spillover effect,” Dr. Huang said. “Either way, the study demonstrated that delirium can be prevented in some patients.”
There is some limited evidence supporting pharmacologic prevention of delirium, he added. A 2005 study in the Journal of the American Geriatric Society of patients undergoing hip surgery found that those who took 1.5 mg of haloperidol per day one to three days preoperatively, and continuing through three days postoperatively, had a shorter delirium duration and length of stay compared to those taking placebo, although incidence of postoperative delirium did not differ between the groups.
Not all cases of delirium can be prevented, however. For those in whom it isn’t, effective treatments include minimizing the use of catheters, IV lines, restraints and telemetry; correcting dehydration; addressing bowel and bladder issues; ruling out infection; reorienting the patient; monitoring nutrition; providing hearing and visual aids; and mobilizing the patient.
“One of my pet peeves is doctors who order bed rest for patients with delirium. I think in many cases activity with assistance is best indicated, though there are certainly instances where bed rest is appropriate,” Dr. Huang said.
To avoid disturbing the sleep-wake cycle, physicians should prescribe medications to be taken fewer times in a 24-hour period when possible, and locate the patient’s bed closer to a window to provide a better sense of day and night, he added.
There is little evidence for the use of antipsychotics in patients with mild, non-agitated delirium. For those with significant delirium/agitation, a Cochrane review found haloperidol is best, Dr. Huang said. Caution should be exercised in using this drug with cardiac patients, he added: “You may want to take a baseline EKG to look at the QT interval before prescribing this drug.”.
Doctor seizes on topic of epilepsy
Martin Samuels, MACP, may have waited until the second day of the precourse on neurology to discuss epilepsy, but not because he considers the condition unimportant.
“This is the second-most important neurological disease in the world, after stroke,” said Dr. Samuels, who is chairman of the department of neurology at Brigham and Women’s Hospital in Boston.
Epilepsy is more common in the developing world, due to infections like cysticercosis, but the incidence of seizures in the U.S. is also significant. “One in 10 of us is going to have a seizure in our lifetime, but no more than one-third [of that 10%] is going to have a tendency to recurrent seizures,” Dr. Samuels said.
The distinction between a single seizure and a diagnosis of epilepsy is not just semantics, Dr. Samuels noted. “Be very careful about writing the word epilepsy in anybody’s record until they are an epileptic,” he told attendees. He cautioned that being diagnosed as an epileptic can affect a patient’s access to insurance and employment.
Treatment will likely also depend on this distinction. “Pharmacologically treating every seizure doesn’t make sense,” Dr. Samuels said. For example, if a patient has suffered a seizure due to alcohol withdrawal, anti-epileptic medications (which are no longer called anti-convulsants to clarify their indication) could do more harm than good.
However, depending on their occupation, some patients may require treatment after their first seizure. Dr. Samuels described the case of a surgeon who suffered a single dramatic seizure, the cause of which was not initially clear. In order to be cleared to operate, the surgeon elected to take anti-epileptic medication even though he was not technically epileptic.
Determining the cause of a seizure is one of the first steps in management, Dr. Samuels advised. Causes are typically categorized as either genetic or symptomatic.
Etiology varies with age. For example, developmental, traumatic and infectious causes are more common among children and young people, while the most common cause among the elderly is cerebrovascular disease.
“When you’re facing a patient with seizure, you ought to think, at what age did this start?” said Dr. Samuels. The incidence of seizures also varies by age, with the young and the elderly having more seizures than middle-aged people.
Dr. Samuels debunked a common assumption about the causes of seizures in middle-aged patients. “There is no age group in which a brain tumor is the most common cause of seizure. The idea that a seizure in mid-life means a brain tumor is not correct.”
In addition to assessing the cause of a seizure, internists should determine whether the event was partial or generalized. A partial seizure results from a malfunction in any single part in the brain. Therefore, its manifestation can be in any function of the brain. “Anything you can imagine, and many things you can’t imagine, could be a seizure,” said Dr. Samuels, listing numbness in different parts of the body, movement of a single body part, and even déjŕ vu as examples. These types of seizures are most easily identified by their recurrence.
“Within reason, it will be the same time after time,” said Dr. Samuels. “The cause of this thing—scar, tumor, genetic—is going to emanate from the same place.”
Generalized seizures affect the entire brain and are associated with a loss of consciousness. However, they can still be difficult to identify. In some cases, patients may lose consciousness so briefly that it’s not apparent.
And even in cases where consciousness is obviously lost, there are a number of differential diagnoses to consider. “How do we know it’s not syncope?” asked Dr. Samuels. “That’s a tough one.” Syncope is usually preceded by feelings of dizziness or faintness and episodes are shorter than seizures. But it’s commonly assumed that incontinence indicates an epileptic seizure, and that’s not actually a definitive determinant, Dr. Samuels said. An epileptic may have an empty bladder, or a person with a psychogenic nonepileptic seizure may be deliberately incontinent.
Psychogenic nonepileptic seizures are challenging to deal with, Dr. Samuels said. “It’s not much better than having epilepsy. You still fall down, embarrass yourself, can’t drive,” he explained. Such seizures are more common in women, and do occur in some people who also have epilepsy.
There are also a number of tests that may be useful in trying to understand the causes of a patient’s seizure. Dr. Samuels recommended that physicians measure a patient’s complete blood count, electrolytes, calcium, magnesium, liver function and renal function. An EEG and MRI should also be performed. “You don’t have to be admitted for this workup, provided there’s good support at home,” said Dr. Samuels.
People who have had a seizure also need to be warned about any necessary changes to their home routines. State laws vary on how long they have to be seizure-free to drive. Dr. Samuels also warns patients not to bathe babies and—although it may seem obvious—engage in other potentially dangerous activities.
“I had a doctor who said to me, ‘Can I fly my plane?’” said Dr. Samuels, to laughter from the audience.
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Annals and ACP announce recipients of Junior Investigator Recognition Award
Annals of Internal Medicine and the American College of Physicians will award Crystal Smith-Spangler, ACP Associate Member, and William Harvey, MD, MSc, with the Junior Investigator Recognition Award today at Internal Medicine 2011. The honor is given to junior internal medicine physicians and investigators for original research and review articles published in Annals of Internal Medicine.
“As young researchers, Dr. Smith-Spangler and Dr. Harvey have published articles that have the potential to influence the practice of internal medicine,” said Christine Laine, FACP, MPH, editor-in-chief of Annals and Senior Vice President of ACP. “We look forward to seeing the implications of their work in clinical practice.”
Now in its first year, Annals’ Junior Investigator Recognition Awards will be presented annually to two junior physicians.
Dr. Smith-Spangler is being recognized for the article she authored while in training. “Population Strategies to Decrease Sodium Intake and the Burden of Cardiovascular Disease: A Cost-Effectiveness Analysis” was published in the April 20, 2010, issue of Annals.
Dr. Harvey is being honored for an article he authored within three years of completing his training. “Association of Leg-Length Inequality with Knee Osteoarthritis: A Cohort Study” was published in the March 2, 2010, issue of Annals.
Read more about the award and its recipients online.
Session on CAP and HCAP canceled
Friday’s session “A Map to CAP and HCAP: Approaching Pneumonias” (MTP 086) has been canceled. The session was scheduled to be held from 7-8 a.m. in Ballroom 20A..
Keynote speaker to address 'medicine as practice'
This year’s keynote speaker will be Richard J. Baron, MACP, founder of Greenhouse Internists in Philadelphia, who will speak on the practice of medicine at this year’s opening ceremony on Thursday, April 7, 9:30-10:30 a.m., in Hall D.
Dr. Baron founded Greenhouse Internists, a community-based internal medicine practice now employing seven physicians, in 1989. Greenhouse is part of a pilot project for the patient-centered medical home.
In April 2010, Dr. Baron’s study detailing the uncompensated work burden on primary care physicians was published in the New England Journal of Medicine. The study used computerized patient records and reporting systems to track all the “invisible” tasks performed at Greenhouse over the year before funding from the pilot project was received.
“The study’s message is that the current payment system for internists and other primary care physicians does not work,” Dr. Baron said. “Billing for every phone call and e-mail would be burdensome and expensive for our offices, but getting paid an annual lump sum per patient recognizing the actual non-visit based services our patients need could help primary care physicians focus on providing high value services to patients.”
Dr. Baron has received a variety of honors, including the Directors’ Award for his service in the National Health Service Corps, the 2010 “Practitioner of the Year” award from the Philadelphia County Medical Society, and the Richard and Hinda Rosenthal award from ACP for his work at Health Partners on improving delivery of preventive care services to children. ACP also has honored Dr. Baron by giving him the Pennsylvania Laureate Award and naming him a Master in 2010.
In 2001, Dr. Baron was named to the American Board of Internal Medicine (ABIM). He was chair at ABIM from July 2008 to June 2009 and now serves as a trustee at the ABIM Foundation. He serves on the Standards Committee for the National Committee for Quality Assurance and became a board member of the National Quality Forum in December 2009.
Dr. Baron earned his undergraduate degree in English at Harvard and his medical degree at Yale. He is board certified in internal medicine and geriatrics..
Cardiology update will help physicians communicate risks, benefits and harms
Advances in cardiology require physicians to convey difficult concepts to patients, either about risks or the likelihood of disease prevention after various treatments. At today’s Update in Cardiology, to be held from 11:15 a.m to 12:45 p.m. in Ballroom 20D, Rita F. Redberg, MD, MSc, will review the latest research on topics including statins, stents, defibrillators and genetics. She will also discuss patient communication issues, such as including clear risks and benefits, and alternative therapies in informed consent discussions.
Guidelines from the American College of Cardiology/American Heart Association suggest statin therapy should be prescribed to lower low-density lipoprotein levels in people who are at high risk for heart disease from multiple risk factors. Yet data to support the benefits of statins in primary prevention are not well established, and questions about adverse events remain unanswered. Dr. Redberg will review two studies on the issue, one from Archives of Internal Medicine and one from the Cochrane Collaboration.
“In the last 10 years, a lot of the focus for primary prevention has been on cholesterol,” she said. “There are good things that you can do to reduce your chances of having heart disease, and in these studies, they call into question [the singular focus on cholesterol].”
The first study, a meta-analysis, looked at the entire literature since 1970 on the use of statins, and found that the drugs have no benefit on all-cause mortality. The meta-analysis combined data from 11 randomized trials involving 65,229 participants, followed for approximately 244,000 person-years, 2,793 of whom died. Researchers found no statistically significant benefit of statins on mortality, even in the highest-risk primary prevention group.
This lack of benefit in high-risk patients makes it extremely unlikely that primary preventive use of statins in lower-risk patients would lead to mortality benefits, Dr. Redberg said. Combined with the Cochrane review, the results deliver a message to move away from statins and toward lifestyle changes for primary prevention.
“Primary prevention is a critically important topic in heart disease because heart disease is largely preventable or we can delay the onset,” Dr. Redberg said. “We have a lot of room for improvement in how we are doing that.”
Genetics are another evolving topic. One study published in Annals of Internal Medicine reviewed a population of 526 nondiabetic patients who were being referred to coronary angiography and compared how well researchers could predict obstructive coronary artery disease (CAD) with and without the use of gene expression profiles.
While genetic testing for CAD risk is an exciting prospect, Dr. Redberg said, this study found that a new gene expression test only modestly predicted presence of obstructive CAD beyond standard clinical variables such as age, sex and chest pain type. It seems likely that the gene expression changes in this study are associated with CAD, its risk factors or its disease-responsive factors, but are not causal.
“Genetics are an interesting area of active research and investigation, but clinically, their utility is not established,” Dr. Redberg said.
In another study published in Annals of Internal Medicine, researchers surveyed cardiologists and patients scheduled for elective cardiac catheterization and possible percutaneous coronary intervention (PCI) at one academic medical center. Two-thirds of the patients had any angina, 42% had activity-limiting angina and 77% had a positive stress test.
One-third of the patients went on to get PCI, all but four on the same day as the diagnostic catheterization. Angina was similar in patients who did and did not go on to get PCI. Cardiologists were more likely than their patients to believe the patient was experiencing angina before the PCI and more likely to believe that the patient participated in the decision to proceed with PCI.
Nearly all patients stated that they knew why they might get PCI, but 88% said it would reduce their chance of having a heart attack and 82% believed it would reduce their chance of a fatal one. Most cardiologists believed the benefits of PCI were mainly symptom relief. However, even in scenarios where they did not identify any benefit of PCI, 43% of cardiologists indicated they would still do one.
“It was striking that a lot of patients thought they were having this elective PCI because it would prevent having a heart attack. And that’s not true,” Dr. Redberg said. PCI is no better than optimal medical therapy for prevention of heart attack and death, and physicians need to find ways to communicate that to patients, she noted.
“It seems that physicians are not transmitting that information to patients, or patients are not hearing it clearly,” Dr. Redberg said. Informed consent is crucial in these situations, but same-day PCIs may not allow for meaningful discussions about benefits and risks. Dr. Redberg’s talk will include effective ways to obtain true informed consent from patients.
Other topic areas will include results from the ACCORD study trials, appropriate use of implantable cardioverter defibrillators, transcatheter aortic valve implants, and cognitive behavioral therapy to prevent recurrent cardiovascular events..
Health care technology briefings to be held at ACP's EHR Forum
ACP staff and informatics physician experts will present informal, 15-minute “Technology Briefings” in the EHR Forum (Booth #643). The topics address timely and practical issues that physicians need to understand in order to succeed in the computer age of medical practice, including ICD-10, e-prescribing, meaningful use, EHR implementation, and using technology in the medical home and accountable care organizations. Speakers will include ACP staff, informatics faculty, and other experts.
Thursday, April 7
|10:45-11:00 a.m.||Coping with Chart Conversion|
|11:00-11:15 a.m.||Qualifying for Meaningful Use|
|1:00-1:15 p.m.||e-Rx Penalty–June 2011 Deadline|
|1:30-1:45 p.m.||Six Steps for EHR Selection|
|4:00-4:15 p.m.||Preparing for ICD-10|
|4:15-4:30 p.m.||HIT and Advanced Care Models|
Friday, April 8
|10:45-11:00 a.m.||Six Steps for EHR Selection|
|11:00-11:15 a.m.||Coping with Chart Conversion|
|1:00-1:15 p.m.||Qualifying for Meaningful Use|
|1:45-2:00 p.m.||e-Rx Penalty–June 2011 Deadline|
|4:00-4:15 p.m.||Preparing for ICD-10|
|4:15-4:30 p.m.||Are You Ready for an EHR?|
Saturday, April 9
|10:45-11:00 a.m.||Qualifying for Meaningful Use|
|11:00-11:15 a.m.||Six Steps for EHR Selection|
|1:00-1:15 p.m.||e-Rx Penalty–June 2011 Deadline|
ACP Annual Business Meeting to be held Saturday in Room 17
All Members, Fellows, Masters, Associates and Affiliates are encouraged to attend ACP's Annual Business Meeting at Internal Medicine 2011. Incoming Officers, new Regents and Governors-Elect will be introduced.
The meeting will be held Saturday in Room 17 at the San Diego Convention Center from 12:45 p.m. to 1:45 p.m., with J. Fred Ralston Jr., FACP, ACP President, presiding. Dennis R. Schaberg, MACP, will present the Annual Report of the Treasurer. A key feature of the meeting is the presentation of ACP's priorities for 2011-2012 by Executive Vice President and Chief Executive Officer Steven E. Weinberger, FACP. Members will have the opportunity to ask questions following Dr. Weinberger's presentation.
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