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

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Internal Medicine 2013 News



Scientific Meeting News for April 11, 2013




Highlights

Internists learn to do orthopedics during precourse

When patients come to internists with musculoskeletal complaints, they are usually looking for pain relief. But the first step in diagnosis might cause the patient pain, precourse director Robert K. Cato, MD, FACP, told attendees at Tuesday's "Orthopedics for the Practicing Internist." More...

Docs need to step up HIV screening

All doctors, whether inpatient, outpatient or specialist, should screen all patients age 13 through 64 for HIV per Centers for Disease Control and Prevention guidelines, said the presenter at a talk on HIV at Wednesday's hospital medicine precourse. More...

Ezekiel J. Emanuel to address health care reform in keynote address

This year's keynote speaker, Ezekiel J. Emanuel, MD, PhD, FACP, will speak on health care reform at Internal Medicine 2013's opening ceremony today at 9:30-10:30 a.m. in Hall D. More...


Breaking news

ACP releases clinical guidelines app

Internal medicine physicians and other clinicians can now access evidence-based clinical recommendations from ACP through the ACP Clinical Guidelines mobile app. More...

Annals, ACP announce recipients of Junior Investigator Recognition Awards

Annals of Internal Medicine and ACP will honor Adrienne Allen, MD, MPH, and Matthew Spitzer, MD, ACP Associate Member, with Junior Investigator Recognition Awards at Internal Medicine 2013. Both honorees will be on site in San Francisco this Saturday to present their winning research. More...


For attendees

Advancement to Fellowship consultation sessions offered

ACP is offering several "Advancement to Fellowship" consultation sessions at Internal Medicine 2013. More...

Panel to review role of subspecialists in the patient-centered medical home

A panel presentation today, held from 11:15 a.m. to 12:45 p.m. in Room 130, will provide a brief overview of the College's policies on how to be a "good neighbor" when applying the patient-centered medical home model. More...

Top topics on tap for general internal medicine

Top articles in 2012 addressed topics familiar to every internist—obesity, prostate cancer, and the proper use of aspirin—and this year's Update in General Internal Medicine will view these areas through the filter of high-value care, said Robert K. Cato, MD, FACP. More...


Highlights


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Internists learn to do orthopedics during precourse

When patients come to internists with musculoskeletal complaints, they are usually looking for pain relief. But the first step in diagnosis might cause the patient pain, precourse director Robert K. Cato, MD, FACP, told attendees at Tuesday's "Orthopedics for the Practicing Internist."

"You are supposed to hurt the patient so you can find out where it hurts," he said, noting that internists, especially those without much orthopedics training or experience, may be reluctant to apply the force required for accurate diagnosis.

He and faculty Kevin M. Fosnocht, MD, FACP, and W. Richey Neuman, MD, FACP, did their best to correct that and other common misconceptions about orthopedics by not only lecturing the internists in attendance, but also leading them in quick self-examinations of their own joints. The course leaders offered a painful-sounding acronym for their diagnostic process: HIT ME (or history, inspect, touch, move, extra maneuvers).

Dr. Cato is an associate professor of clinical medicine at the University of Pennsylvania in Philadelphia, where Drs. Fosnocht and Neuman are assistant professors of clinical medicine. Their background might sound unusual for teaching an orthopedics course, but internists are qualified to diagnose, and even treat, these problems, they said. "Most musculoskeletal complaints can be managed without specialty consultation," said Dr. Cato.

Of course, surgical cases (and fractures) need to be referred, but internists can ensure that their patients receive high-value, efficient care by taking care of their needs up until that point. Avoiding unnecessary imaging is one major way to improve the efficiency of care, Dr. Cato said. "In many cases, imaging is not useful because it's a tendon thing," he said.

Incidental findings on imaging can also lead to missed diagnoses. For example, studies have found that MRIs will show that 35% of asymptomatic patients over age 60 have a herniated disc, Dr. Neuman reported. So finding a herniated disc does not mean you've found the cause of a patient's back pain. "We image the spine way too much, especially the lumbar sacral spine. Most of the cases of low back pain and even neck pain, you're not going to need to do imaging," Dr. Neuman said.

Imaging should be reserved mostly for patients with "red flag" symptoms (those that suggest cancer, fracture or other serious problems), cases where it would confirm a diagnosis and affect treatment, and patients who are being referred for surgery. "Surgeons love that" when internists speed the process by ordering the necessary imaging before referring a patient, Dr. Cato said.

Before ordering that image and referral, however, internists should assess the appropriateness of surgery, advised Dr. Cato. "I believe that we should be deciding when a patient needs surgery," he said. "If you have knee arthritis, hip arthritis, many times the patient does not need surgery. ... If the patient says, 'I can get by with this,' they can get by."

There are a number of treatments internists can offer to help patients get by with, or fully recover from, their musculoskeletal problems. Dr. Cato offered some pearls on the best uses of them.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a common solution, and internists should be comfortable with multiple classes of them, so they have something to offer patients who haven't found relief with the one they're taking.

Acetaminophen can be a good alternative for the many musculoskeletal problems where inflammation is not a major issue. It provides the same analgesia and may be safer. The maximum dose should be 3 grams per day, Dr. Cato said.

Narcotics should only be used for acute problems, he recommended. "If I don't have a definite endpoint, I don't start them anymore."

He does often start patients on physical therapy, if exercise would help their condition. Unlike many areas of orthopedics, "There are data backing it up," he said. However, if the exercises are simple and the patient is self-motivated and/or has high co-pays, a referral might not be necessary. "For uncomplicated conditions like neck pain or back pain, the exercises aren't complicated and I can give patients a handout," Dr. Cato said.

There's less data support for many of the other common treatments for orthopedic problems, including ice and heat. "I never heard of anybody being damaged by ice or heat, so I recommend empirically," said Dr. Cato. Also, corticosteroid injections have mixed data support, but many physicians feel that their patients benefit. They're generally safe, as long as you don't inject directly into a tendon, Dr. Cato said. "You'll know if you're in the tendon. There's going to be a lot of resistance."

Chiropractors are also probably OK, except for patients with acute radiculopathy. If patients have favorite alternative supplements, Dr. Cato generally goes along with that, too, although he suspects it may be a waste of money. Physicians should think more carefully, however, about the potential waste of referring for spinal or epidural injections. "It's a hugely expensive endeavor. Sometimes we make the referral because we have nothing else to offer, but we should realize it's very expensive," Dr. Cato said.

In general, however, the lesson of the precourse was that internists have much to offer their patients with musculoskeletal problems. "Many musculoskeletal complaints in primary care are not bone- or joint-related. In almost all cases, you should be able to come to a working diagnosis," said Dr. Cato.


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Docs need to step up HIV screening

"As doctors, if we miss one person with diabetes or heart disease, that one person may die. If we miss one person with HIV, it could be that person, plus his or her partners, and their partners, and so on," said Stacey Rizza, MD, chair of HIV and outpatient infectious disease at Mayo Clinic in Rochester, Minn., during a talk on HIV at the hospital medicine precourse on Wednesday.

All doctors, whether inpatient, outpatient or specialist, should screen all patients age 13 through 64 for HIV per Centers for Disease Control and Prevention guidelines, said Dr. Rizza, who is an associate professor of medicine at Mayo.

"This applies to the 63-year-old woman coming in for the hip replacement, as well as the 21-year-old man with a cold," Dr. Rizza said. "The initial test isn't based on risk."

People with known risk should have repeat HIV testing at least annually, she added. For everyone else, the current recommendation is once in a lifetime "because this has found to be cost-effective. We don't have the numbers yet to advocate for or against more frequent testing."

Though the guidelines recommend telling patients you will be doing HIV screening, the screening is an "opt-out test," so general consent for medical care is all that's required to do the test, she said.

Unfortunately, she added, "Doctors are terrible about doing these screenings." Institutions that receive funding through the Ryan White HIV/AIDS Program have a 60% screening rate, while non-Ryan White institutions have only a 10% to 15% screening rate, she said.

The screenings are reimbursed by insurance, Medicare and Medicaid, she added.

If you get positive test results back, order serologies for hepatitis A, B, C, cytomegalovirus (CMV) and varicella-zoster virus (VZV). Also, as part of the baseline laboratory evaluation, get a CD4 cell count and percentage, and do a screening for other sexually transmitted diseases, Dr. Rizza said. Both men and women also should have an anal Pap smear, since HIV brings a higher incidence of squamous cell carcinoma of the anus, she said.

Starting treatment immediately is usually not necessary. "There's almost never an urgent need to leap into HIV treatment, though you may need to treat the opportunistic infections right away," Dr. Rizza said.

Instead, try to dig down into the reasons your patient may have contracted the disease. Inquire about the possible date of infection by determining if there have been recent new sexual partners or intravenous drug use, and when (if at all) the last negative HIV test result was. Also determine if there are other medical conditions, and screen for signs and symptoms of prior opportunistic infections like shingles, chicken pox, jaundice, hepatitis and other sexually transmitted diseases, she said.

Ask, too, about potential exposure history, such as from traveling or volunteering at a homeless shelter, vaccination history, and social environment, Dr. Rizza said.

"A patient's social situation is the most important part. Look at whether the person comes from a stable home environment, has stable employment, insurance or other ability to pay for medications, any chemical dependencies or mental health issues," she said.

When talking to the patient, it's important to counsel and comfort, Dr. Rizza noted. "Remember this person has found out while alone in the hospital, without family and friends nearby, and with strangers coming in and out of the room."

One piece of good news you can tell your patients is that, while there is no cure for HIV, good treatment exists, she said.

There are many drug options for treating HIV, but the basic formula for antiretroviral therapy is to use three active drugs from at least two different classes. The classes include nucleoside analogue reverse transcriptase inhibitors (NRTIs or "nucs"), non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors, entry inhibitors, and integrase inhibitors.

"Usually, it's two nucs and one drug from one of the other classes," Dr. Rizza said.

It's extremely important that patients be able to commit to taking all three drugs every single day; otherwise, he or she may experience viral resistance. The rule is "all pills or no pills," meaning it's better to take no pills at all than to only take some of them, she said.

"You have to carefully assess the patient's likelihood of compliance," Dr. Rizza said.

Patients who faithfully take their medication can substantially reduce the risk of disease transmission to partners, she added. In 2011, the National Institutes of Health announced it had halted a five-year study after two years, because the study found transmission to partners was reduced by 96% in patients who used antiretrovirals.

"If we identify all the people who have HIV, and we treat them, we can virtually wipe out transmission," Dr. Rizza said.


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Ezekiel J. Emanuel to address health care reform in keynote address

This year's keynote speaker, Ezekiel J. Emanuel, MD, PhD, FACP, will speak on health care reform at Internal Medicine 2013's opening ceremony today at 9:30-10:30 a.m. in Hall D.

Dr. Emanuel is vice provost for global initiatives, and chair of the department of medical ethics and health policy, and the Diane v.S. Levy and Robert M. Levy University Professor at the University of Pennsylvania in Philadelphia. He is also an Op-Ed contributor to The New York Times. His keynote address is titled "The Physician Responsibility to Lead on Implementing Health Care Reform."

He was the founding chair of the department of bioethics at the National Institutes of Health and held that position until August 2011. Until January 2011, he served as a special advisor on health policy to the director of the Office of Management and Budget and National Economic Council. He is also a breast oncologist and author.

After completing Amherst College, Dr. Emanuel received his MSc from Oxford University in Biochemistry. He received his MD from Harvard Medical School and his PhD in political philosophy from Harvard University.



Breaking news


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ACP releases clinical guidelines app

Internal medicine physicians and other clinicians can now access evidence-based clinical recommendations from ACP through the ACP Clinical Guidelines mobile app.

Available for free on iPhone, iPad, and Android at iTunes.com and android.com, the ACP Clinical Guidelines app includes recommendations from ACP's clinical practice guidelines and guidance statements. Users can conveniently access clinical recommendations and rationale, summary tables, algorithms and advice on high-value care for all currently active guidelines in an easy-to–read, interactive mobile format.


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Annals, ACP announce recipients of Junior Investigator Recognition Awards

Annals of Internal Medicine and ACP will honor Adrienne Allen, MD, MPH, and Matthew Spitzer, MD, ACP Associate Member, with Junior Investigator Recognition Awards at Internal Medicine 2013. Both honorees will be on site in San Francisco this Saturday to present their winning research.

Now in its third year, Annals' Junior Investigator Recognition Awards are presented annually to two junior physicians. Annals and ACP recognize 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. Allen, associate medical director of quality, safety, and risk at North Shore Physicians Group in Boston, is being recognized for an article she authored while in training, "Pharmacy Dispensing of Electronically Discontinued Medications," which was published in the Nov. 20, 2012, Annals of Internal Medicine.

Dr. Spitzer, an endocrinology fellow at Boston Medical Center, is being recognized for an article he authored within three years of completing his training, "Effects of Testosterone Replacement on Response to Sildenafil Citrate in Men with Erectile Dysfunction: A Parallel, Randomized Trial," which was also published in the Nov. 20, 2012, Annals of Internal Medicine.

Winners are selected based on their 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 ACP's Education and Publication Committee.



For attendees


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Advancement to Fellowship consultation sessions offered

ACP is offering several "Advancement to Fellowship" consultation sessions at Internal Medicine 2013.

The sessions will be held at 10:30 a.m. today and at 10:30 a.m. and 3:45 p.m. on Friday, April 12, at the Membership Booth in the ACP Resource Center (Booth 825 in the Exhibit Hall). Each of the three sessions will be led by Capt. Jeffrey B. Cole, MC, USN, FACP, chair of ACP's Credentials Committee. The Friday afternoon session is intended especially for international members, and Spanish-speaking staff will be present to translate information and questions. Fellowship application materials will be available for all eligible members.


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Panel to review role of subspecialists in the patient-centered medical home

A panel presentation today, held from 11:15 a.m. to 12:45 p.m. in Room 130, will provide a brief overview of the College's policies on how to be a "good neighbor" when applying the patient-centered medical home (PCMH) model.

By using a case example, the panel will demonstrate how realistic, practice-based procedures and workflow changes can improve internists' abilities to provide more effective and efficient care and be a "good neighbor" with subspecialty clinicians. The panel will be moderated by M. Carol Greenlee, MD, FACP, coauthor of the College's "medical neighborhood" policy paper and vice-chair of the College's Council of Subspecialty Societies.

The panel will demonstrate how the implementation of the College's "medical neighborhood" recommendations provide a pathway to achieving this National Committee on Quality Assurance Patient-Centered Specialty Practice recognition, as well as an opportunity to become a preferred clinician for health plans, other payers, and new developing payment models (e.g., accountable care organizations) that require participating practices to ensure a high degree of care coordination and integration.


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Top topics on tap for general internal medicine

Top articles in 2012 addressed topics familiar to every internist—obesity, prostate cancer, and the proper use of aspirin—and this year's Update in General Internal Medicine will view these areas through the filter of high-value care, said Robert K. Cato, MD, FACP.

Dr. Cato and his co-moderator, Matthew H. Rusk, MD, FACP, based their presentation, which will take place today from 11:15 a.m. to 12:45 p.m. in Room 134, on the College's recent emphasis on therapies that work well, have proven efficacy, and are inexpensive.

"Sometimes less is more in terms of things like prostate cancer screening or treatment with things like aspirin as opposed to more aggressive treatments," said Dr. Cato, who is associate professor of clinical medicine at the University of Pennsylvania in Philadelphia. "High-value care is certainly a major theme for the ACP and something that I completely endorse."

Drs. Cato and Rusk culled the literature throughout the year using tools such as ACP's JournalWISE to assess the biggest studies in the highest-impact journals, such as Annals of Internal Medicine, and narrow the search to their top 10.

Screening for osteoporosis quickly became an obvious finalist for the update, Dr. Cato said. In the New England Journal of Medicine, a study with 20-year follow-up found that among nearly 5,000 women age 67 and older, osteoporosis developed in fewer than 10% during rescreening intervals of approximately 15 years in those with normal bone density or mild osteopenia, five years for those with moderate osteopenia, and one year for those with advanced osteopenia.

"That informs us about how often the test needs to be done," Dr. Cato said. "As it turns out, it doesn't need to be done as often as many people do [it]. It allows us to provide high-value care with less cost."

Two other high-value care options involve aspirin, a drug that Dr. Cato notes costs less than one penny a day as a therapy.

The WARFASA (Warfarin and Aspirin) study concluded that aspirin reduced the risk of recurrence when given to patients with unprovoked venous thromboembolism who had discontinued anticoagulant treatment, with no apparent increase in the risk of major bleeding.

"Sometimes we use very expensive medicine to prevent blood clots," Dr. Cato said. "This is, again, one penny a day with virtually no risk—a very inexpensive opportunity to provide high-value care that would really change management."

A second aspirin study also suggests the regimen as a high-value way to prevent stroke in patients with congestive heart failure. The WARCEF (Warfarin Versus Aspirin in Reduced Cardiac Ejection Fraction) study, also published in the New England Journal of Medicine, randomized people with reduced left ventricular ejection fraction who were in sinus rhythm to getting an aspirin a day or receiving warfarin. There was no significant overall difference between treatment with warfarin and treatment with aspirin, while a reduced risk of ischemic stroke with warfarin was offset by an increased risk of major hemorrhage.

"The patients who took an aspirin had the same number of strokes and death as the patients who took the blood thinner [warfarin], which has more side effects and is very annoying and cumbersome to use," Dr. Cato said. "The theme, again, is good old aspirin is effective."

For prostate cancer, Drs. Cato and Rusk looked at two studies. PIVOT (Prostate Cancer Intervention versus Observation Trial) examined men diagnosed with localized prostate cancer. Half the men were randomized to surgery and half were not. Those who had surgery didn't really do any better and didn't live any longer than those who didn't have surgery.

"It's a real strange thing to tell a patient that we're going to diagnose you with cancer but we're not going to treat you," Dr. Cato said. "There was really no difference between the two groups. It wasn't the perfect study that ended all controversy on the subject, but it was the first time that anyone had ever shown that."

The second study questioned the value of even screening for prostate cancer with prostate-specific antigen (PSA) blood tests. This follow-up from a previous study looked at data as far as 11 years out for patients randomized to PSA screening or no PSA screening. The people who were screened did not live longer than the people who were not, though there was a small reduction in prostate cancer deaths.

"Both of these studies really, really raise the question together as to whether we should even be screening for prostate cancer at all or whether we ought to just skip the whole thing, which is just a huge, huge controversy out there," Dr. Cato said. "And these two studies together really add more evidence to suggest that we should not really be screening for prostate cancer at all."

Internists face obesity every day in their offices, and two more studies on the topic made this year's top 10 list.

One study looked at a combination of topiramate and phentermine given to patients for two years. One-third of those treated with just lifestyle and nutrition education lost more than 5% of their weight, compared to three-quarters of patients taking the medicine.

But, Dr. Cato points out, long-term drug safety remains unknown and researchers still haven't shown that the regimen will prevent consequences of obesity, such as diabetes, heart attacks or strokes.

A second study compared bariatric surgery to counseling on proper diet and exercise. At one year, almost half of the patients who had the surgery had their diabetes perfectly controlled, while lifestyle counseling resulted in one in nine patients achieving diabetes control.





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