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Internal Medicine 2013 News



Scientific Meeting News for April 12, 2013




Highlights

Party drugs require hard work to spot and treat

During his session "Drugs of Abuse," Osama A. Abulseoud, MD, offered advice on the common presentations of drug problems, including cystitis, panic attacks and 10-hour episodes of psychosis. More...

Using medical applications on wards, in clinics

Sameer Badlani, MD, FACP, advised Internal Medicine 2013 attendees to eschew cloud-based technology while embracing some bedside clinical consult platforms and health information technologies. More...

Making sense of movement disorders

Martin A. Samuels, MD, MACP, described novel ways to evaluate patients with movement disorders, including a staring contest and evaluating the natural tendency to fidget. More...


Breaking news

New recommendations offer ethical guidance for social media

Social media developments require physicians to consider how to best protect patient interests and apply principles of professionalism to online settings, ACP and the Federation of State Medical Boards (FSMB) said yesterday in a new policy paper, "Online Medical Professionalism: Patient and Public Relationships." More...


For attendees

Engaging in improved transitions of care

Today's panel discussion on "Managing Transitions: An Essential Element for Effective and Efficient Care Delivery" will focus on how physicians within multiple settings have been able to improve their ability to provide care that is better integrated/coordinated with the rest of their medical neighborhood through the implementation of specific practice changes. More...

Infectious diseases update to address breakthroughs, controversies

General internists looking for a relevant recap of the year's greatest hits in infectious disease research can find it at this morning's Update in Infectious Diseases. More...

Hospital medicine update follows mock patient's experience

Today's Update in Hospital Medicine culled details from 90 of the most important studies in hospital medicine to present a fictional patient's course through her hospital stay, from admission through complications to an eventually successful outcome. More...


Highlights


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Party drugs require hard work to spot and treat

Special K, Super C, spice. It was 7 a.m. on Thursday, but speaker Osama A. Abulseoud, MD, wasn't listing breakfast options for Internal Medicine attendees.

These terms, along with others like cat valium and ivory wave, may be used by patients to describe illegal drugs they've taken. During his session "Drugs of Abuse," Dr. Abulseoud, assistant professor of psychiatry and psychology at Mayo Clinic in Rochester, Minn., offered advice on the common presentations of drug problems.

"The history is important" for identifying abuse of some of these drugs, because they are not caught by standard urine tests, Dr. Abulseoud said. For example, ketamine (also known as Special K, Super C and cat valium) won't show up on a drug test but can cause serious medical problems for users.

Typical consequences of repeated use include psychosis and memory impairment, but ketamine users may also present with cystitis, a less obvious clue to drug abuse. In some cases, the problem can be so severe as to require bladder reconstruction, Dr. Abulseoud said.

The pain associated with ketamine-induced cystitis can also create a vicious cycle. "Patients sometimes self-medicate with more ketamine. In this case, you have to treat the pain aggressively. Otherwise the patient will not be able to stop," he said. Antidepressants can also help patients get off ketamine, he added.

Serotonin is also an issue with bath salts, another drug that's been gaining popularity in the U.S. People who have used this drug (which is sold under this misleading name and labeled as "not for human consumption" in order to evade drug regulations) may present with serotonin syndrome, because the drug causes a massive release of neurotransmitters.

"Imagine that you use cocaine and methamphetamine together," said Dr. Abulseoud. "You can imagine the rush the patients will get."

But when patients come down from that high, they may suffer terrible panic attacks, psychosis (sometimes violent and aggressive) and, for unknown reasons, green tongues. "We don't have an antidote. But we can use benzodiazepines and antipsychotics that will calm the patient," said Dr. Abulseoud.

Antipsychotics may also be necessary for some patients who've taken synthetic marijuana (also known as spice). It poses a much higher risk than traditional marijuana of causing psychosis, which can be very long-lasting, requiring as much as 10 days of inpatient care. "Use an antipsychotic and then you would sit next to the patient and pray that this case resolves quickly," he said.

Synthetic marijuana is a relatively new drug, and got its start in the pharmaceutical companies' efforts to replicate the pain relief and antiemetic properties of natural marijuana. Their efforts were unsuccessful but opened the door for other chemists to create synthetic marijuana. "It became public knowledge how to make agonists," he said. "The use of spice increased significantly in 2009, 2010, 2011." Synthetic marijuana is another drug that's sold widely with the claim that it's not for human consumption.

Access is also no obstacle to abusing Salvia divinorum, a common garden plant. "In traditional Mexican culture, it was used for religious purposes," he said. Salvia causes brief, intense hallucinations and can exacerbate preexisting mental health problems. "The patient who is depressed and started using salvia starts thinking about suicide," he said. Unfortunately, there's no treatment except support, but the good news is that most episodes resolve on their own.

Internists should take a much more active role in dealing with the next drug abuse problem on Dr. Abulseoud's list—opioid addiction. The United States has fewer than 5% of the world's population but consumes 80% of the opioid supply, he reported. Prescription rates have been steadily increasing since 1999. "The more we prescribe, the more people die," Dr. Abulseoud said. "The number of deaths due to opioid overdose is actually greater than the number of suicides and traffic accidents."

To combat this problem, physicians should restrict the conditions they treat with opioids. "We are giving opioids right and left, and the patients are asking for opioids right and left," he said. "There is no evidence for treating noncancer, chronic pain with opioids." Another potential solution would be to create a national database of opioid prescriptions to prevent patients visiting multiple physicians and pharmacies, Dr. Abulseoud suggested.

Internists, particularly hospitalists, can also help patients recover from their addiction to opioids by properly treating methadone withdrawal. An audience response quiz during the session showed that many internists' current practices do not conform to Dr. Abulseoud's recommendations. When asked how to treat an emergency department patient who he had been receiving methadone in another city and was now going through withdrawal, about 40% of attendees answered (using the audience response system) that they'd send him on his way with a clonidine prescription.

Dr. Abulseoud would prefer admission and methadone treatment. "We get a little scared about using clonidine," he said. One problem with clonidine is that it has less effect on the subjective symptoms of withdrawal, which could make patients more likely to relapse. If you do want to use it, it's better to admit the patient to allow titration of the dose and treatment of his or her troublesome symptoms, he advised. Providing reassurance is also key.

"When they hear you aren't giving them any methadone, they freak out," he said. "The most important thing to tell the patient is, 'Don't worry, we're here to assure your comfort.'"


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Using medical applications on wards, in clinics

Beware of the cloud, and embrace PIER.

That was the advice of Sameer Badlani, MD, FACP, who moderated a Thursday session of Internal Medicine 2013 with two colleagues on using medical applications on the wards and in the clinic. During the session, audience members were encouraged to use their mobile devices to text questions and answer polls, results of which appeared instantly on one of two screens up front.

"I would discourage you from using cloud-based technology until you have your IT [information technology] department do a full security analysis," said Dr. Badlani, a hospitalist and chief medical information officer at the University of Chicago.

ACP's Physician's Information and Education Resource (PIER), on the other hand, garnered his thumbs-up because it takes you to information quickly and specifies the level of evidence supporting its recommendations. Dr. Badlani demonstrated the latter function on-screen.

"You see this little 'A' at the end of the line? This means the evidence is based on a randomized, controlled trial. I don't know about you, but I always like to see the letter 'A.' Getting a 'B' in my family was like having a learning disability. So, click on the 'A' and you get more information about the research," he said.

During the fast-paced, interactive session, the speakers reviewed many other popular software applications, as well as particularly useful features of electronic health records.

The four big categories of software apps used by physicians are medical calculators, clinical knowledge bases, medication tools and antibiotic tools, said John Pell, MD, a hospitalist and IT physician liaison at University of Colorado.

Clinical decision-making resources clinicians might use on the wards include PIER, UpToDate, Dynamed, STAT!Ref, MD Consult/First Consult and Pocket Medicine. Resources for digging deeper into a subject are Google Scholar, PubMed-Medline, WebMD, Medscape, Cochrane Library and online textbooks, he said.

There are several mobile antibiotic management applications on the market, but the John's Hopkins Antibiotic Guide and the Sanford Guide received the highest scores for content and usability in an evaluation by three infectious disease specialists that was published in Clinical Infectious Diseases, Dr. Pell noted.

Moving on to the best features of EHRs in the inpatient setting, one is a pre-rounding report that captures and summarizes data obtained in the last 24 hours, he said.

Dashboards also are useful to monitor one's patients in real time throughout the day. Medication/condition flow sheets give more detailed and organized information on patients to see trends over time and responses to therapy, Dr. Pell added.

"Work with your IT physician representatives to optimize the content and format of these tools," he advised. "Part of our job is to push our IT departments to make sure they are giving us what we want."

Dr. Badlani also gave case-based examples of how technological tools can be used. One involved a 72-year-old male patient with a medical history of hypertension who was admitted to the hospital from clinic for hypercalcemia (11.2 mg/dL) found on routine labs, along with an elevated phosphate (6.2 mg/dL) and a low albumin (3.0 mg/dL). The patient took 40 mg daily of lisinopril and his brother had prostate cancer, but there was no other family history of malignancy.

"The history on this guy is that his wife is a big fan of Dr. Oz, and she heard that vitamin D is really good for you, so she started giving him a lot of it. And he started having constipation, and just was not acting the same," Dr. Badlani said. "So here I am, I sort of remember that albumin has a correlation with calcium, but how do I know this is really hypercalcemia before I start giving him IV fluids or bisphosphonates?"

To answer this, a physician can use a medical calculator to determine the effective serum calcium value for the patient. "I would go to MDCalc.com," Dr. Badlani said. "I type in the patient's values, and it tells me this is definitely a real hypercalcemia."

To determine what do about the patient's hypercalcemia, "I go to PIER, to the diagnosis section, then 'laboratory and other studies' and it provides a useful table" that describes the tests one can order to get more specific information about the patient's condition, he said.

Another benefit of PIER is that it tells you when the module was last updated, which helps if you know that a practice-altering study has recently been published on the topic.

"UptoDate has a great usability interface, but I really question their input. ... They give a whole list of references, but I don't know if they are Level A references," Dr. Badlani said.

Using apps and gadgets to help with diagnosis and management is great, but employing them during patient encounters can be tricky, noted C.T. Lin, MD, FACP, the chief medical information officer at the University of Colorado Health.

"You want to engage the patient in the use of the computer through triangulation. Invite the patient to review information on your computer or mobile device. Have them sit side by side with you. Verbalize what you are you doing on your device in the presence of the patient," Dr. Lin said.

Some patients may feel a little uncomfortable with the technology at first, so you can ease them in with something simple, like looking up the last progress note, or the results of a blood test, he said.

"I had a patient who never quite got the [hemoglobin] A1c concept until she saw the red line for 'normal,' and that she was above it," Dr. Lin said.

Things you shouldn't do in front of patients include complaining about technology, he added.

"Don't go on about how slow the network has been all day. In the patient's eyes, it just reflects poorly on you for choosing that network," Dr. Lin said.

Also, don't write notes on the computer in front of your patient without asking permission. Jotting down short phrases, which can be fleshed out later, is a good strategy, he said.

And of course, you should also remember to log out of applications which contain protected patient information, refrain from sending SMS/texts or unsecured e-mails with protected patient information, and avoid putting patient information on a device that isn't password-protected or encrypted, he said.


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Making sense of movement disorders

At his Thursday morning session "Approach to the Patient with Movement Disorders," Martin A. Samuels, MD, MACP, described one way that he evaluates patients with bradykinesia: He holds a staring contest.

"I compare my eye blink rate with the patient's eye blink rate," he said. "I watch them blink, then I blink, and then we see who blinks next. The problem with these people is they win every time."

Kidding aside, Dr. Samuels, who is the founding chair of the department of neurology at Brigham and Women's Hospital and professor of neurology at Harvard Medical School in Boston, also asked the audience to do an experiment to simulate how a bradykinetic patient feels. "It's an extremely unpleasant sensation," he said. He asked everyone to sit without moving, swallowing or blinking for 15 seconds, then listen to all of the "makeup" sounds of shuffling, position shifting and throat clearing when time was up.

His demonstration drove home his point. "The nervous system is meant to move," he said. "[Bradykinesia] is an active suppression that's happening, which is actually painful and difficult. If you had to do that for a minute or two minutes or five minutes, you would find it extremely uncomfortable."

The lack of movement characteristic of bradykinesia leads to dry eyes, difficulty swallowing and the need to think about everything you do, including remembering to move your arms when you walk, Dr. Samuels said. It's most easily recognized by simple observation.

"You have to become good at seeing bradykinesia," he said. "It's subtle when it's early. So you're looking for reduced movements, reduced blinking, these complaints related to not being able to move spontaneously."

Another movement disorder, rigidity, can be caused by three different kinds of increased tone, Dr. Samuels said: spasticity, lead pipe rigidity and paratonia.

"Spasticity can be very disabling," Dr. Samuels said. "It can be worse than paralysis. Some people who have spinal cord injuries will tell you that their weakness is bad but the spasticity is worse, that the stiffness is so severe that they can't uncross their legs, for example, to do personal hygiene."

Physicians can detect spasticity by moving the limb quickly, said Dr. Samuels. If you move the limb more slowly, you won't feel the same degree of stiffness, since the disorder is velocity-dependent.

Lead pipe stiffness, however, has nothing to do with velocity, Dr. Samuels said. It's independent of the speed at which the limb moves. Paratonia, which is effort-dependent, is a kind of stiffness in which "I push, he pulls," Dr. Samuels said. For example, if you tell a patient to relax and then you pull on the affected limb, the patient will push you away. The stiffness disappears if you distract the person, Dr. Samuels said.

Paratonia can be due to a lesion in the frontal lobe or can be the result of a patient trying to fake muscle weakness, he said. "I've never had a person who could imitate spasticity or lead pipe stiffness," he said. "I don't think it can be done."

Dr. Samuels also discussed a movement disorder that's not a disorder at all: fasciculation, or muscle twitching.

"The word that you should write in your notes next to the word 'fasciculation' is the word 'normal,'" Dr. Samuels said. "Everybody here has had one."

Fasciculation, which emanates from the motor unit and is related to cramp, is meaningless when not accompanied by weakness and wasting, Dr. Samuels said. "It's hard to cure something that isn't a disease," he said. "It isn't our job to stop everything on earth."

If patients with fasciculation want to try to stop it, they can take quinine or magnesium, and antiepileptic drugs might work, Dr. Samuels said. "But you're really hitting a mosquito with a sledgehammer."



Breaking news


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New recommendations offer ethical guidance for social media

Social media developments require physicians to consider how to best protect patient interests and apply principles of professionalism to online settings, ACP and the Federation of State Medical Boards (FSMB) said yesterday in a new policy paper, "Online Medical Professionalism: Patient and Public Relationships."

"Digital communications and social media use continue to increase in popularity among the public and the medical profession," said Phyllis Guze, MD, FACP, chair of ACP's Board of Regents. "This policy paper provides needed guidance on best practices to inform standards for the professional conduct of physicians online."

Published online at www.acponline.org and www.annals.org and in the April 16 Annals of Internal Medicine, the paper examines and provides recommendations regarding the influence of social media on the patient-physician relationship. It also addresses the role of online media and public perception of physician behaviors and strategies for patient-physician communications that preserve confidentiality while best utilizing new technologies.

"It is important for physicians to be aware of the implications for confidentiality and how the use of online media for non-clinical purposes impacts trust in the medical profession," said Humayun Chaudhry, DO, MS, FACP, president and CEO of FSMB.

Notable recommendations from ACP and FSMB include the following:

  • Physicians should keep their professional and personal personas separate. Physicians should not "friend" or contact patients through personal social media.
  • Physicians should not use text messaging for medical interactions even with an established patient except with extreme caution and consent by the patient.
  • E-mail or other electronic communications should only be used by physicians within an established patient-physician relationship and with patient consent.
  • Situations in which a physician is approached through electronic means for clinical advice in the absence of a patient-physician relationship should be handled with judgment and usually should be addressed with encouragement that the individual schedule an office visit or, in the case of an urgent matter, go to the nearest emergency department.
  • Establishing a professional profile so that it "appears" first during a search, instead of a physician ranking site, can provide some measure of control that the information read by patients prior to the initial encounter or thereafter is accurate.
  • Many trainees may inadvertently harm their future careers by not responsibly posting material or actively policing their online content. Educational programs stressing a proactive approach to digital image (online reputation) are good forums to introduce these potential repercussions.

The paper includes a chart of online activities, potential benefits and dangers, and recommended safeguards for physician behavior.

For example, communicating with patients using e-mail offers the potential benefits of great accessibility and immediacy of answers to non-urgent issues. The potential dangers are confidentiality concerns, replacement of face-to-face or phone interaction, and ambiguity or misinterpretation of digital interactions. The safeguards include reserving digital communications for patients that maintain face-to-face follow-up only.

The paper was authored by ACP's Ethics, Professionalism and Human Rights Committee; ACP's Council of Associates; and FSMB's Committee on Ethics and Professionalism.



For attendees


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Engaging in improved transitions of care

Today's panel discussion on "Managing Transitions: An Essential Element for Effective and Efficient Care Delivery" will be held from 2:15 to 3:45 p.m. in Room 130 and will focus on how physicians within multiple settings have been able to improve their ability to provide care that is better integrated/coordinated with the rest of their medical neighborhood through the implementation of specific practice changes.

Panelists include representatives from primary care, hospital, and two distinct specialty settings, endocrinology and oncology, including John V. Cox, DO, FACP; Lauren B. Doctoroff, MD; Yul D. Ejnes, MD, MACP; and M. Carol Greenlee, MD, FACP.


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Infectious diseases update to address breakthroughs, controversies

According to presenter Bennett Lorber, MD, MACP, general internists looking for a relevant recap of 2012's greatest hits in infectious disease research can find it at this morning's Update in Infectious Diseases, to be held from 8:15 to 9:15 a.m. in Room 134.

"What I tried to do was to pick clinically based papers that would be interesting and of use to general internists. I didn't pick papers that were directed specifically to infectious disease doctors, but rather to the audience of the annual meeting," said Dr. Lorber, who is Thomas M. Durant Professor of Medicine at Temple University in Philadelphia.

One of those papers, published in the Journal of the American Medical Association, tackles the effectiveness of antibiotics in the typical patient with sinusitis. "I like this paper because it was a randomized, controlled trial done in primary care office practices," Dr. Lorber said. One group of patients was treated with antibiotics, another was treated with placebo, and all were asked about their symptoms at days 3, 7 and 10. No significant difference was found between the groups.

"This is important because we don't want to give any more antibiotics than we have to," Dr. Lorber said. "The largest area of antibiotic use in this country now is to treat upper respiratory tract infections, including sinusitis, and it turns out that they don't do any good."

Another paper represents "a complete paradigm shift in our understanding of urinary tract infections," according to Dr. Lorber. The study, which was published in Clinical Infectious Diseases, screened young women with recurrent urinary tract infections (UTIs) to see if they also had asymptomatic bacteriuria.

The prevailing thinking has been that patients with recurrent UTIs and asymptomatic bacteriuria would get fewer UTIs if the bacteriuria were treated, but this study found just the opposite, according to Dr. Lorber. Women who were given antibiotics for asymptomatic bacteriuria actually had increased risk for subsequent infection, and treatment was also associated with infections related to more resistant organisms.

"Doctors shouldn't screen for or treat asymptomatic bacteriuria in young women with recurrent urinary tract infections," Dr. Lorber stressed.

Another topic to be covered in the update is the debate over recurrent Lyme disease. A study published in the New England Journal of Medicine looked at patients with a first episode of erythema migrans who were treated with antibiotics and then later developed the rash again.

"A lot of people have thought that [the second rash] represents relapse of latent infection … and therefore you need to treat them with more antibiotics for a longer period of time," Dr. Lorber said. However, the study authors performed molecular studies in people with second episodes of erythema migrans and found that they were reinfected, not relapsing, and could be treated exactly the same as they were for the first episode, Dr. Lorber said.

Dr. Lorber will also discuss the emergence of a new tickborne pathogen in Missouri, described in the New England Journal of Medicine, and another New England Journal of Medicine paper defining a subset of patients with endocarditis who appear to benefit from early surgery. Finally, he will address the underlying cause of the nationwide epidemic of fungal meningitis that occurred in 2012.

"I'm going to talk about what compounding pharmacies are, what they should do and what they shouldn't do, and how we really need improved regulatory control of compounding pharmacies to prevent this kind of nightmare," Dr. Lorber said.


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Hospital medicine update follows mock patient's experience

A. Scott Keller, MD, FACP, co-moderator of today's Update in Hospital Medicine, which will be held from 9:30 to 10:30 a.m. in Room 134, is nothing if not diligent. To prepare for his talk, he created an anonymous online survey asking colleagues if they would rather go to an update that explained a few studies in depth or one that discussed more studies in less detail.

Most of his fellow hospitalists at the Mayo Clinic in Rochester, Minn. chose the latter, so Dr. Keller culled through a pool of about 90 studies looking for the most important. He then consulted with co-moderator James S. Newman, MD, FACP, and another colleague at Mayo, Tamara E. Buechler, MD, ACP Member. In the end, 11 studies made the cut.

Once the decision was made, Drs. Keller and Newman constructed a narrative of "Mrs. Xavier," an elderly patient whose hospital course they will describe during the session, touching upon relevant studies as they go.

Ms. Xavier is admitted with pneumonia and hip fracture, Dr. Keller explained. Her warfarin, which she takes for atrial fibrillation, is stopped for hip surgery, so the hospitalist service must determine how best to resume anticoagulation postoperatively.

In this commonly encountered situation, guidelines recommend patients receive bridging therapy, but there are different scenarios on when to start, Dr. Keller noted. Hospitalists therefore must do their best to balance the risk of venous thromboembolism (VTE) with that of bleeding.

"Existing guidelines are weighted more toward preventing VTE, but a study came out this past year showing the risk of clot is lower than anticipated, while the risk of bleeding may be higher," he said. "What's more, the study gave a timeline, saying that if you wait 48 hours to resume anticoagulation, you can lower that risk of bleeding compared to waiting just 24 hours."

It's an example of a study that "adds a missing link" to existing guidelines, Dr. Keller added. "Anticoagulation after surgery is one of those issues we struggle with every single day," he said. The question of when to anticoagulate arises again when Ms. Xavier develops an upper gastrointestinal bleed in the course of her hospitalization, Dr. Keller said.

Another perioperative issue hospitalists deal with frequently is myocardial infarction (MI), and several studies on the subject will be highlighted in the update. One found that elderly hip fracture patients, like Ms. Xavier, have a higher risk of MI after surgery than current guidelines suggest, Dr. Keller said.

"It emphasizes that maybe the surgery is more stressful than we think," Dr. Keller said. "And it raises the question: Should hip fracture surgery be considered a higher-risk procedure?"

As for poor Ms. Xavier, she goes into full cardiac arrest in the days following surgery, and her hospitalists must determine how long to continue cardiopulmonary resuscitation. Luckily for her, her code team was aware of last year's Lancet study which suggests that longer CPR could improve survival.

"Hospitals in the highest quartile for length of CPR effort had more people who survived to discharge than those in the lowest quartile. This lesson applies to hospitalists, code teams and rapid response teams," Dr. Keller said.

Once Ms. Xavier is successfully resuscitated, the hospitalist team struggles to deal with her desire to leave the hospital too soon and her family's desire to keep her in the hospital too long. Dr. Keller provides evidence to help hospitalists discuss these issues with patients and families under both circumstances.

"Things work out for Ms. Xavier, but there are bumps in the road," Dr. Keller said. "This was a huge year for research" for hospitalists, he added. "This is especially the case for studies that apply to a broader range of inpatients, rather than small niches."





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