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

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Internal Medicine 2012 News



Scientific Meeting News for April 19, 2012




Highlights

'PharManure' and the drugs you hate the most

A lecture on newly approved medications is a common feature of medical conferences. Not as many session speakers also update you on the drugs they hate the most. More...

Like gambling? Eat raw oysters

If you're considering sampling local seafood while in town, you might want to steer clear of raw oysters, said Thomas A. Moore, MD, FACP, chair of infectious diseases at Oschner Medical Center in New Orleans, at a talk during Wednesday's Hospital Medicine precourse. More...


Breaking news

ACP launches mobile-optimized literature resource

The American College of Physicians released ACP JournalWise, a personalized, mobile-optimized updating service for clinical articles from a large number of medical journals, at Internal Medicine 2012. More...

Annals, ACP announce recipients of Junior Investigator Recognition Award

Annals of Internal Medicine and the American College of Physicians will award Nak-Hyun Kim, MD, and Benjamin J. Powers, MD, MHS, with the Junior Investigator Recognition Award on Friday, April 20, at Internal Medicine 2012. The honor is given to junior internal medicine physicians and investigators for original research and review articles published in Annals of Internal Medicine. More...


For attendees

Mobile access and interaction at Internal Medicine 2012

ACP has worked to make the meeting more accessible and engaging by expanding our mobile features. Take advantage of the following to get the most out of Internal Medicine 2012. More...

Earn MOC points at Internal Medicine 2012

For the first time, attending the annual meeting can qualify for Maintenance of Certification (MOC) credit. Internal Medicine 2012 attendees can earn up to 30 points toward the American Board of Internal Medicine's Self-Evaluation of Medical Knowledge requirement by attending sessions and completing one, two, or three multiple-choice question modules. There is no additional fee for these points. More...

Keynote speaker to address health disparities, inequity in era of health reform

This year's keynote speaker is Wayne J. Riley, MD, MBA, MACP, president and chief executive officer of Meharry Medical College in Nashville, Tenn., who will speak on "Health Disparities and Inequity in the Era of Health Reform: Why Internal Medicine Must Lead the Way." The keynote address will be given during the Opening Ceremony on Thursday, April 19, 9:30-10:30 a.m. in Hall I-2. More...

Gastroenterology/hepatology update will recap a banner year

Those who attend the Update in Gastroenterology and Hepatology today can expect a recap of a banner year in the field, according to Norton J. Greenberger, MD, MACP, clinical professor of medicine at Harvard School of Medicine in Boston. More...

Session to discuss 'news you can use' in clinical guidelines

Today's session "News You Can Use: Current Clinical Guidelines" will review up-to-date clinical guidelines and high-value, cost-conscious care. More...


Highlights


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'PharManure' and the drugs you hate the most

A lecture on newly approved medications is a common feature of medical conferences. Not as many session speakers also update you on the drugs they hate the most.

But during Wednesday's "Advances in Therapy" precourse, general internist Christopher L. Knight, MD, FACP, offered his perspective on both topics, as well as describing some new uses for old medications.

Drugs were likely to make his "PharManure" list if they increased health care costs without improving care. Offenders included intravenous acetaminophen, the new spray form of zolpidem, co-pay coupons for branded minocyclines, and new combinations of older drugs, such as ibuprofen/famotidine and naproxen/esomeprazole.

"Last I checked you could get a big jar of naproxen pills and a modest thing of esomeprazole for less than $110/month," said Dr. Knight, who is an associate professor of medicine at the University of Washington.

On the other hand, some new uses that researchers have recently found for already existing medications could prove to be cost-effective. Starting with the least expensive, a recent study found that a placebo, when dosed open label, provided slight improvement in irritable bowel syndrome (IBS). The lesson isn't that you should give all your IBS patients placebos, said Dr. Knight. "But when your patient comes in and tells you something is working, you should listen to them if it doesn't cost a thousand dollars."

Patients might also be talking to their internists about the new indication for tadalafil (Cialis). The drug is now FDA-approved to treat benign prostate hyperplasia, based on a study that compared it to tamsulosin. "Interestingly, there was greater quality of life improvement with tadalafil," Dr. Knight said, to laughs from the audience. This new indication may ease the pre-authorization process for the drug, he added.

Quality of life improvement was also seen in a study of selenium for treatment of Graves' orbitopathy. Based on that and reductions in eyelid aperture, the drug seems like a good option for patients with this specific condition, but not those with Graves' disease and no eye problem, or everyone in general, given other recent findings.

"This study was published a month before another study saying that selenium is a heavy metal and shouldn't be in all kinds of supplements," said Dr. Knight.

He also gave cautionary advice about the new use for azithromycin to reduce chronic obstructive pulmonary disease (COPD) exacerbations. In a trial, the antibiotic provided a 35% absolute reduction in exacerbations, but individual and widespread resistance is a concern. "I just worry about putting lots of people on antibiotics for long periods of time," Dr. Knight said.

The risk of eventual resistance is also a concern with one of the new drugs he highlighted in the talk. Ceftaroline has proven to be effective against methicillin-resistant Staphylococcus aureus (MRSA), including isolates that are resistant to vancomycin.

"I love this drug. That said, I think there are good reasons we shouldn't use it," said Dr. Knight. "You don't use a drug that treats vancomycin-resistant bugs; you save it."

Other drugs that he urged cautious enthusiasm about included telaprevir and boceprevir, FDA-approved for hepatitis C virus (HCV) last year. The drugs improved outcomes and appear to hold potential for short-course treatment, but even 24 weeks of therapy may be out of reach financially for many HCV patients. "You're looking at somewhere between 30 and 50 grand," said Dr. Knight.

Somewhat less expensive, but still potentially pricey, is ulipristal, an emergency contraceptive that appears to be effective in controlling bleeding in women with fibroids. And to round out the new drugs, Dr. Knight mentioned fidaxomicin for Clostridium difficile (cures about like vancomycin but costs a whole lot more) and roflumilast (prevents exacerbations in patients with severe COPD, but can cause depression and anxiety).

He also drew attention to rifapentine, a treatment for tuberculosis. "It's not a new drug. But I had never heard of it," he said. It's a weekly drug that only has to be given for three months, which would have been much appreciated by a recent patient of Dr. Knight's who had undergone nine months of daily isonicotinylhydrazine. "He was miserable for the nine months. He hated taking the pills and had to stay away from his usual glass of wine," he said.

Another drug that's definitely not new, but worth talking to your patients about, is sunscreen. An Australian study found that a five-year trial of telling people to put sunscreen on their face and hands every day resulted in reduced skin cancer even 15 years later.

"If you're in a sunny place, this is a reasonable thing to recommend to patients," Dr. Knight said—a good lesson for precourse attendees to take along as they head back into the New Orleans sunshine.


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Like gambling? Eat raw oysters

If you're considering sampling local seafood while in town, you might want to steer clear of raw oysters, said Thomas A. Moore, MD, FACP, chair of infectious diseases at Oschner Medical Center in New Orleans, at a talk during Wednesday's Hospital Medicine precourse.

"There are many reasons not to eat them. Hepatitis A is one; another is toxoplasmosis. The biggest risk factor for acquiring this parasitic infection is the consumption of raw oysters," Dr. Moore said. "It's like Russian roulette. Eating [raw oysters] is OK now and then, but if you go on a bender, you're gonna get it," he said.

Another risk—and the subject of a portion of his talk—is Vibrio vulnificus. The organism is part of the normal marine flora, especially oysters, and tends to cause disease in warmer months. With a mortality rate of 50%, it accounts for 90% of all seafood-related U.S. deaths. A few years ago, The Sunday Times (of London) food critic Michael Winner nearly lost his leg from contracting the illness after eating a bad oyster, Dr. Moore noted.

Cases related to V. vulnificus have been increasing along the Gulf Coast, "perhaps due to global warming," Dr. Moore said.

Refraining from eating the raw mollusks won't entirely protect you from the skin and soft tissue infection caused by the organism, though, as it can be contracted from nonfoodborne exposure too, he said. Still, 90% of patients who get ill from V. vulnificus report having eaten oysters within the previous seven days, he noted.

Typically, the illness starts with abrupt onset of rigors, then fever and prostration. This is followed by hypotension in a third of cases. In 75% of cases, metastatic skin lesions develop with 36 hours of initial symptom onset, usually on the extremities, with the legs being more common than the arms. Leukopenia and thrombocytopenia are also common, but not universal, he said.

"Vibrio vulnificus is primarily associated with severe, distinctive soft tissue infection and/or septicemia," Dr. Moore said. "What you usually don't see is diarrhea; it invades the bloodstream without causing [gastrointestinal] symptoms."

Patients typically develop sepsis within 16 hours of symptoms and cellulitis somewhere between four hours and four days (the mean time is 12 hours), he said.

Physicians should consider V. vulnificus when a patient has septicemia associated with necrotizing skin lesions; is immunocompromised, as with liver disease; and has ingested or was exposed to oysters and/or salt water in the past one to three days.

If you do suspect V. vulnificus, be sure to alert the lab that is performing tests, as it may otherwise be missed. Only 25% of labs in Gulf Coast states routinely culture for the bacteria, he said.

In treating complicated skin and soft tissue infection due to V. vulnificus, the best option is tetracycline. Other good options include ceftriaxone and ciprofloxacin.

Patients with cellulitis from V. vulnificus respond well to antibiotics, but early diagnosis is critical as the condition progresses rapidly, Dr. Moore added. Early surgical consultation is also advised. "These patients often need early and aggressive debridement," he said.

Patients who have developed bacteremia don't respond as well to treatment, though starting antibiotics within 24 hours of the onset of symptoms does help lower mortality for these folks, he said.

Those who still want to ingest raw oysters after learning the potential consequences can lower their chances of getting sick by using tabasco, noted Dr. Moore. Research suggests the vinegar in the condiment inhibits the growth of V. vulnificus, so the higher the vinegar content of your chosen brand, the better, he said.

Oh, and cooked oysters? Totally safe, he said.



Breaking news


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ACP launches mobile-optimized literature resource

The American College of Physicians released ACP JournalWise, a personalized, mobile-optimized updating service for clinical articles from a large number of medical journals, at Internal Medicine 2012.

"ACP JournalWise alerts users to the highest-quality, most clinically relevant new articles for internal medicine and its subspecialties," said Virginia L. Hood, MBBS, MPH, FACP, ACP's outgoing president. "Users can quickly access the literature that matters the most to them based on their interests."

Updated daily and available on smartphone, tablet, or desktop, ACP JournalWise screens articles in every issue of over 120 journals identifying specialty area, methods quality, and clinical importance. It also gathers the tables of contents of journals users select from a list of more than 175 in one convenient place for browsing. Features include the following:

  • Select the specialty areas and the rating thresholds for article alerts;
  • Check new alerts by logging in from smartphone, tablet, or computer, or opt for e-mail alerts at specified frequency;
  • Search the ACP JournalWise database for quality-assessed articles on specific topics;
  • Follow the tables of contents of favorite journals as new issues become available;
  • Save links to favorite articles for future use;
  • Share alerts with peers, and follow what they are reading;
  • Read expert commentary on high-quality, clinically relevant articles; and
  • Scan the most popular articles across all specialties.

ACP JournalWise is a free benefit for ACP members and is managed by the editors of Annals of Internal Medicine. It will soon be available for non-member purchase.

ACP members can set up their free subscription online. Existing ACP Journal Club PLUS subscribers will have their accounts automatically transferred to ACP JournalWise.


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Annals, ACP announce recipients of Junior Investigator Recognition Award

Annals of Internal Medicine and the American College of Physicians will award Nak-Hyun Kim, MD, and Benjamin J. Powers, MD, MHS, with the Junior Investigator Recognition Award on Friday, April 20, at Internal Medicine 2012. 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. Kim and Dr. Powers have published articles on clinical issues that affect many internists practicing medicine today," said Christine Laine, MD, MPH, FACP, editor-in-chief of Annals and senior vice president of ACP. "Their research is important because it will influence the way doctors care for their patients."

Now in its second year, Annals' Junior Investigator Recognition Award is presented annually to two junior physicians. Annals and ACP give an award for the most outstanding article by a first author who is in an internal medicine residency program or a general medicine or internal medicine subspecialty fellowship program. An award also is given for the most outstanding article with a first author who is within three years of completing his or her training in internal medicine or one of its subspecialties.

Dr. Powers will accept his award in person. He is assistant professor of medicine at the Duke University Medical Center Department of Medicine in Durham, N.C. and a staff physician at the Durham Veterans Affairs Medical Center. He is being recognized for the article he authored within three years of completing his training. "Measuring Blood Pressure for Decision Making and Quality Reporting: Where and How Many Measures?" was published in the June 21, 2011 Annals of Internal Medicine.

Dr. Kim, a resident at Seoul National University College of Medicine in Seoul, Korea, is being honored for an article he authored while in training. "Effect of Routine Sterile Gloving on Contamination Rates in Blood Culture: A Cluster Randomized Trial" was published in the February 1, 2011 Annals of Internal Medicine.

Selection of award winners considers the article's novelty, methodological rigor, clarity of presentation, and potential to influence practice, policy, or future research. Judges include Annals' editors and representatives from Annals' editorial board and the American College of Physicians' Education/Publication Committee.



For attendees


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Mobile access and interaction at Internal Medicine 2012

ACP has worked to make the meeting more accessible and engaging by expanding our mobile features. Take advantage of the following to get the most out of Internal Medicine 2012.

Download the Internal Medicine 2012 Meeting App for iPhone or Android. The app includes complete searchable schedules of scientific sessions, ACP events, and industry-sponsored educational events, allowing you to build your own schedule. You will also find helpful information, such as exhibitor listings, maps, and daily news from the meeting.

View or download handouts online.

Use Twitter to connect to news and announcements from ACP. Use hashtag #im2012 when you share tweets about the meeting.

Stay connected to ACP at the meeting and afterward on Facebook.

Free wireless Internet is available at the Cyber Centers located outside Exhibit Hall G/H and inside the Exhibit Hall at Booth 1349.


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Earn MOC points at Internal Medicine 2012

For the first time, attending the annual meeting can qualify for Maintenance of Certification (MOC) credit. Internal Medicine 2012 attendees can earn up to 30 points toward the American Board of Internal Medicine's Self-Evaluation of Medical Knowledge requirement by attending sessions and completing one, two, or three multiple-choice question modules. There is no additional fee for these points.

Modules are now available in the "preview mode" online. Read through the questions to determine which topics you need to brush up on. Questions are cross-referenced to scientific program sessions. Identify the sessions you'll want to attend at Internal Medicine 2012 according to your individual learning needs.

On April 22, the live version of the modules will be available to Internal Medicine 2012 attendees at the same URL. Sign in with your ACP Online username and complete one, two, or three modules. Successful completion of each module—a score of 60% or higher—qualifies for 10 ABIM MOC points. Modules must be completed by March 31, 2013.

Each 25-question module spans a broad range of clinically relevant topics:

  • cardiology,
  • critical care,
  • dermatology,
  • endocrinology,
  • gastroenterology,
  • geriatrics,
  • hematology,
  • infectious diseases,
  • nephrology,
  • neurology,
  • oncology,
  • pulmonary medicine,
  • rheumatology,
  • women's health and
  • sports medicine.

If you have questions about the Internal Medicine 2012 MOC Modules or any of the other ways that ACP can help you prepare for ABIM recertification, stop by the ACP Resource Center, located at Booth 1039 in the Exhibit Hall. ACP staff will be on hand to answer your questions.


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Keynote speaker to address health disparities, inequity in era of health reform

This year's keynote speaker is Wayne J. Riley, MD, MBA, MACP, president and chief executive officer of Meharry Medical College in Nashville, Tenn., who will speak on "Health Disparities and Inequity in the Era of Health Reform: Why Internal Medicine Must Lead the Way." The keynote address will be given during the Opening Ceremony on Thursday, April 19, 9:30-10:30 a.m. in Hall I-2.

Dr. Riley received his medical degree from the Morehouse School of Medicine in 1993 and completed residency training in internal medicine at Baylor College of Medicine in 1996. He is board certified and a diplomate of the American Board of Internal Medicine. He also holds a bachelor's degree in anthropology with a concentration in medical anthropology from Yale University, a master's of public health degree in health systems management from the Tulane University School of Public Health and Tropical Medicine, and a master's of business administration degree from Rice University's Jesse H. Jones Graduate School of Management.

Dr. Riley received the Morehouse School of Medicine's Distinguished Alumnus Award in 2003 and the National Association for Equal Opportunity in Higher Education Distinguished Alumnus Award, which recognizes outstanding alumni from the nation's historically black colleges and universities, in 2006.

A native of New Orleans, Dr. Riley is actively involved in numerous medical professional organizations, including having served as president of the 6,000-member Texas Academy of Internal Medicine, the Texas Chapter of ACP. In 2005, Dr. Riley was elected to the ACP's Board of Governors as Governor-elect for the Texas Southern region. He also served on the Institute of Medicine's Planning Committee "American Medical Schools and the Physician Supply in the United States."


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Gastroenterology/hepatology update will recap a banner year

Those who attend the Update in Gastroenterology and Hepatology today can expect a recap of a banner year in the field, according to Norton J. Greenberger, MD, MACP, clinical professor of medicine at Harvard School of Medicine in Boston.

Dr. Greenberger and his co-moderator, Prateek Sharma, MD, FACP, will cover research from 2011 on Barrett's esophagus and proton-pump inhibitors (PPIs), plus new findings on hyperemesis, mast cell disorders, and pancreatitis and hepatitis, among other topics. The update will be held in Auditorium A from 11:15 a.m.-12:45 p.m.

"Most of [the studies] center on the importance of diagnosis as it relates to treatment, which is why they were selected," Dr. Greenberger said.

Earlier research has suggested that patients with Barrett's esophagus have a 0.5% to 1% chance of developing esophageal adenocarcinoma, which prompted recommendations that this group should undergo surveillance endoscopy every three to five years. A trial in a large Danish population published in the New England Journal of Medicine last year, however, looked at this risk in patients in the general population who had received a diagnosis of Barrett's and found it to be significantly lower, around 0.12%.

Dr. Greenberger pointed out that these results apply to patients who had been diagnosed with Barrett's esophagus but not dysplasia. In patients with Barrett's who were found to have dysplasia on their first endoscopy, the risk of esophageal adenocarcinoma was still significantly higher.

However, given these findings, the suggested intervals at which patients with Barrett's should have a follow-up esophagogastroduodenoscopy or upper endoscopy may need to be revised, Dr. Greenberger said.

Two studies discussed in the update will look at bleeding risk with PPIs. The first, published in Gastroenterology, looked at the risk for upper gastrointestinal (GI) bleeding in patients who were receiving aspirin alone, or aspirin plus warfarin and nonsteroidal anti-inflammatory drugs, and were also taking a PPI. The study found that a PPI can protect against upper GI bleeding in patients in the general population who are receiving dual antiplatelet therapy, Dr. Greenberger said.

The second study, also published in Gastroenterology, examined whether PPIs can protect against recurrent peptic ulcers in patients with atherosclerosis who were taking clopidogrel and had previously had peptic ulcer disease. Patients were randomly assigned to receive clopidogrel alone or clopidogrel plus a PPI. In the first group, the incidence of recurrent peptic ulcers was approximately 10%, compared with approximately 1% in those taking clopidogrel plus a PPI, according to Dr. Greenberger.

"The moral of this story is, if you've had a peptic ulcer and you're going to be on clopidogrel, you need to be on a PPI to prevent recurrent ulceration," he said.

Cyclic vomiting syndrome is usually found in young adults and is characterized by four criteria, Dr. Greenberger said: three or more recurrent episodes of vomiting; intervals of completely normal health between episodes; stereotypical timing and onset of symptoms, usually lasting 24 to 48 hours; and no structural organic disease identified after an exhaustive workup.

A case series published last year in the Mayo Clinic Proceedings described 98 patients whose cyclic vomiting syndrome was related to marijuana use and abuse. "In other words, that's why it's called the cannabinoid hyperemesis syndrome," Dr. Greenberger said.

Physicians need to be aware of this connection, he said, and be alert to the possibility of cannabis abuse in patients who present with a history of cyclic vomiting.

"Those patients should be checked with a 24-hour urine sample, because there can be detectable amounts of cannabis in urine three or four weeks after people have last used the marijuana," he said.

The update will also look at a study by Dr. Greenberger and his colleagues, published in the Journal of Allergy and Clinical Immunology, that described mast cell activation syndrome (MCAS), a relatively new disorder. Patients with this disorder have clinical symptoms that are triggered by heat, exercise, stress and menses and are similar to those of systemic mastocytosis, but they do not have mast cell infiltration, Dr. Greenberger said.

MCAS can be diagnosed by demonstrating very high levels of mast cell mediators such as serum tryptase and urine N-methylhistamine and prostaglandin F2, Dr. Greenberger said. He estimated that about 70% of patients respond dramatically to treatment with anti-mast cell mediator medications such as antihistamine H1 blockers, H2 blockers, mast cell stabilizers such as cromolyn and leukotriene inhibitors.

"Many of these patients have been disabled by these symptoms for years," Dr. Greenberger said. "The average duration of symptoms before the diagnosis was made was 4.9 years. It's a very important disorder, and it's below the radar screen."

A study published in the American Journal of Gastroenterology looked at autoimmune pancreatitis as a distinct form of chronic pancreatitis. Dr. Greenberger described the disorder as relatively new, having come to the medical community's attention in the past 20 years.

"Basically, it's a pancreatic disease that is diagnosable by the HISORt criteria [Histology, Imaging procedure, Serology, Other organ involvement, and Response to treatment]," he said.

Patients will have a lymphoplasmacytic infiltrate in the pancreas on histology, Dr. Greenberger said. Imaging with a CT scan will classically demonstrate an abnormality of the pancreas, and serologic tests will show an elevated serum IgG4 level. Patients with this disorder frequently have trouble with their bile ducts and salivary glands, among other organs, and one-half to two-thirds of patients respond initially to corticosteroids, Dr. Greenberger said.

"If a patient presents with obstructive jaundice and has a CT scan that shows a mass at the head of the pancreas, you have to be careful that you don't just send that patient off to a Whipple procedure to get his pancreas lopped out without checking whether that person might have autoimmune pancreatitis," Dr. Greenberger said.

The treatment for autoimmune pancreatitis is fairly straightforward, he noted: corticosteroids initially and immunosuppressive drugs if the patient does not respond or relapses.

In the field of hepatitis, the update will include discussion of a trial published in the New England Journal of Medicine evaluating the use of telaprevir for retreatment of hepatitis C and hepatitis C virus infection.

Current therapy for hepatitis C, pegylated interferon and ribavirin, is not optimal, Dr. Greenberger said. "In genotype 1 hepatitis C, which is the most common form in the United States, the ability of this regimen to induce a virus-free state, in other words a sustained viral response, is only about 45%," he noted.

Research has focused on whether adding a protease inhibitor as a third drug might result in better sustained viral remission rates. In this trial, patients were randomly assigned to receive dual therapy with pegylated interferon and ribavirin or triple therapy with the addition of telaprevir. The authors found that in patients who had previously not done well on dual therapy, the response rates to triple therapy were as high as 85%.

"It's a landmark study," Dr. Greenberger said, because it means that doctors are now going to have to rethink their approach to treatment-naive patients with hepatitis C. Triple therapy may need to be considered because it could improve the chance of a sustained viral response, he said.

Dr. Greenberger put the significance of the findings into further perspective, noting that there are 4 million people in the United States with hepatitis C, two-thirds to three-quarters of whom have not yet been diagnosed. After a 25-year period, 20% of these patients will have chronic liver disease, Dr. Greenberger said.

"It's important to identify these people and then make as stringent an effort as possible to eradicate the virus," he said. "[Protease inhibitors] are going to make a very significant difference."


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Session to discuss 'news you can use' in clinical guidelines

Today's session "News You Can Use: Current Clinical Guidelines" will review up-to-date clinical guidelines and high-value, cost-conscious care.

Led by moderator Amir Qaseem, MD, PhD, MHA, FACP, the College's director of clinical policy, expert panelists will provide a general overview of the latest clinical guidelines, including venous thromboembolism prophylaxis in hospitalized patients and management of diabetes. The panelists will also discuss overused diagnostic tests, with an emphasis on audience participation.

The session will be held from 11:15 a.m.-12:45 p.m. in Room 356-57.





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