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Internal Medicine Meeting 2016 News



Scientific Meeting News for May 6, 2016




Highlights

Tips for teaching to your own strengths

Teaching students and residents well is not about knowing everything, Kim Manning, MD, FACP, reassured attendees at her Thursday morning session. More...

PPIs, NSAIDs, statins: side effects and warnings to keep in mind for 2016

Douglas S. Paauw, MD, MACP, provided evidence-based pearls on the side effects and warnings attached to fluoroquinolones, proton-pump inhibitors (PPIs), nonsteroidal anti-inflammatory drugs (NSAIDs), and statins. More...

NAFLD treatment starts with weight loss, but can include meds

For nonalcoholic fatty liver disease (NAFLD), "Weight loss works," said Lt. Cmdr. Dawn M. Torres, MD, at her Thursday morning session, "Evolving Paradigms in Chronic Hepatitis." More...


Breaking news

Internists talk about MACRA's major impact

ACP convened a panel yesterday to talk about how the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) and the new payment systems in the law will impact physicians and patients. More...

Guidelines and tools developed for pediatric-to-adult health care transitions initiative

ACP yesterday released guidelines and tools developed to address the gaps that currently exist for the transitions of pediatric patients into adult health care. The toolkit contains disease/condition-specific tools developed by primary care internal medicine and subspecialties to assist physicians in transitioning young adults with chronic diseases/conditions into adult care settings. More...


For attendees

A peek at the Update in Hospital Medicine

John Bulger, DO, MBA, FACP, is admittedly a little bit biased as the co-moderator of the Update in Hospital Medicine. But he advises his colleagues, "if there's one talk you're going to go to, and you're a hospitalist, it should be this one." More...

Update in Women's Health to cover breast cancer, osteoporosis, hormone therapy

Several articles and recommendations published in 2015 have the potential to change internists' management of their female patients, said Melissa McNeil, MD, MPH, MACP. More...


Highlights


.
Tips for teaching to your own strengths

Teaching students and residents well is not about knowing everything, Kim Manning, MD, FACP, reassured attendees at her Thursday morning session.

"I always would think the gold standard was my chair when I was in residency who had this boundless fount of knowledge," said Dr. Manning, who is an associate professor of medicine at Emory University in Atlanta. "I pretty much tried to be him."

Then one day, she had a realization during a conversation with her chief residents. "One of them told me, 'I want to be you.' I realized that was the wrong goal," said Dr. Manning in her session, "Teaching in the Hospital: Strategies to Help You Improve Tomorrow."

Instead, an academic physician's goal should be to capture teachable moments in practice, particularly those that play to the teacher's strengths and the learner's needs. "Most of the time we don't think about what our strengths are," noted Dr. Manning.

Dr. Manning said her strengths include interpersonal interactions with patients and hospital staff. For other physicians, it might be being organized or interpreting CT scans or electrocardiograms. "Do the things that you are good at more frequently with learners," she advised.

To ensure that teaching also matches students' and residents' needs, Dr. Manning recommended observing trainees for 24 to 48 hours after starting to work with them. Then, have a brief goalsetting meeting with the learner and determine how to focus your teaching efforts. "For example, if you decide that the person has an amazing fount of medical knowledge, but they're a little disorganized, you can focus on patient flow," she said.

In some cases it will be easy to see where a trainee needs help, but even superstar residents will have potential areas of improvement, according to Dr. Manning. "Even the strongest and most competent learners can be pushed to new limits," she said.

Dr. Manning noted that the 6 competencies set by the Accreditation Council for Graduate Medical Education can also be helpful in the goalsetting process. Another list that she keeps in mind, and in her pocket on an index card, is the 5 domains for teaching success that were identified by surveying residents and published in a 1992 paper in the Journal of General Internal Medicine. They are learning atmosphere, clinical teaching, teaching style, communicating expectations, and team management.

"The earth-shattering thing to me about this was that medical knowledge was not on there. Knowing everything was not on there," said Dr. Manning.

The atmosphere of a teaching service is an individual choice, but it should be consistent. For example, Dr. Manning tries to be lighthearted, so she greets her learners in the morning with a fun conversation starter, instead of getting right down to business.

She also communicates expectations every day, by establishing an estimated time when rounding will finish based on the patient load. "Everybody is engaged because you know it is going to be over at 11:30," Dr. Manning said. She also asks trainees to set an estimated time when they'll leave the hospital, to help set expectations and comply with duty hours.

Then, during rounds, she makes sure to reveal her reasoning process and provide frequent feedback. "Probably the biggest game changer for you as a teacher is if you start giving feedback all the time. I'm not talking about end-of-the-month or mid-rotation feedback," Dr. Manning said.

She is not a fan of the "feedback sandwich" because it can be confused with casual conversation and not understood as feedback. "I always start with 'Hey, I want to give you some feedback,'" Dr. Manning said.

She does try to be more subtle when teaching what she calls the "hidden hidden" curriculum. "Typically when people talk about the hidden curriculum, it's something bad," said Dr. Manning.

The hidden hidden curriculum includes good things like thinking about patients' lives more broadly. For example, when Dr. Manning texted her trainees a photo of some sneakers she found in the lost and found that would fit a homeless patient with a foot infection, she found that they started thinking more about the issues that would affect patients' well-being after discharge.

"They want to know how we're thinking and what goes into how we regard our patients," she said. "Change the way you think about what's teaching and what's not."


.
PPIs, NSAIDs, statins: side effects and warnings to keep in mind for 2016

The past year brought new scientific findings on drug side effects, as well as some new warnings from the FDA. During his session on medications, Douglas S. Paauw, MD, MACP, provided evidence-based pearls on the side effects and warnings attached to fluoroquinolones, proton-pump inhibitors (PPIs), nonsteroidal anti-inflammatory drugs (NSAIDs), and statins.

Fluoroquinolones have long been linked to peripheral neuropathy and, more recently, tendon rupture. But scrutiny in the past year has revealed other potential side effects, such as aortic disease and collagen-associated adverse events, said Dr. Paauw, a professor at the University of Washington, where he directs medical student teaching for the department of medicine.

He noted that an FDA panel last year agreed that the benefits and risks of fluoroquinolones do not support current labeled indications for the treatment of amniotic band syndrome, acute bacterial exacerbations of chronic bronchitis in patients with chronic obstructive pulmonary disease, or uncomplicated urinary tract infections. Internists should not prescribe fluoroquinolones for these conditions, Dr. Paauw said.

PPIs carry side effects that have been known for a while, such as the association with Clostridium difficile, which the FDA warned clinicians about in 2012. However, new concerns include chronic kidney disease and acute kidney injury, as recent studies found that PPI exposure was associated with a higher risk of both conditions, Dr. Paauw said.

Additionally, a study published last year found that patients receiving PPIs had a significantly increased risk of incident dementia. "This seems to catch our patients' attention," Dr. Paauw said. Stressing that the study does not prove causation, he described the finding as "just another thing to add to our list of what we're worried about with people on PPIs."

Efforts to remove unnecessary PPIs from medication lists have ramped up over the past few years, and a growing body of literature points to other possible problems with the drugs, such as fracture risk, decreased thyroid absorption, and poor absorption of magnesium and vitamin B12, Dr. Paauw said. Because of all these risks, PPIs should be used for the shortest time possible, he recommended.

Although the association of cardiovascular risks with NSAIDs is not new, the FDA last year strengthened label warnings that the drugs may increase patients' risk of myocardial infarction or stroke. Dr. Paauw suggested that internists should steer patients with cardiovascular disease away from NSAIDs. "It doesn't mean you never give NSAIDs to this population, but it is a concern," he said.

Concerns with statins include rhabdomyolysis and acute liver failure, but both are rare, occurring in 0.01% and 0.0001% of patients, respectively, Dr. Paauw said. Of importance, chronic liver disease doesn't appear to be a significant risk of statins, he added. "We really don't need to check liver tests every 3 to 6 months, but patients may ask," and if they do, internists should assure them that due to medical advances, liver tests are no longer necessary, Dr. Paauw said.

More commonly, 5% to 18% of patients may experience statin-associated myalgia, he said, adding that "the whole statin myalgia thing doesn't have great answers." A meta-analysis published last year linked myalgias to lower vitamin D levels, Dr. Paauw noted. A different study found that when vitamin D levels were increased in previously statin-intolerant patients with myalgia, 95% went on to be free of muscle symptoms at 2 years while on statin therapy, he said. Dr. Paauw recommended checking vitamin D as well as creatine kinase (CK) and thyroid-stimulating hormone for patients with statin myalgias.

Such patients should stop taking their statins, and once symptoms disappear, internists should consider restarting at a lower dose or changing the statin, he said. If the patient has recurrent symptoms, Dr. Paauw recommends trying 80 mg of fluvastatin extended release daily or low-dose rosuvastatin daily, every other day, or twice weekly (with the caveat that this dosing's effect on cardiovascular protection is not clear). Internists could also try atorvastatin every other day or, if symptoms persist, ezetimibe, he said.

Although coenzyme Q10 has been investigated as a possible solution, a meta-analysis published last year found no significant effects on muscle pain or plasma CK levels. "It really didn't look like it works for the treatment of myalgias," Dr. Paauw said. "I would keep my eyes open and see if there's more robust data in the future."


.
NAFLD treatment starts with weight loss, but can include meds

For nonalcoholic fatty liver disease (NAFLD), "Weight loss works," said Lt. Cmdr. Dawn M. Torres, MD, at her Thursday morning session, "Evolving Paradigms in Chronic Hepatitis."

"It's the best treatment that there is for NASH [nonalcoholic steatohepatitis]," said Dr. Torres, who is chief of the gastroenterology service in the department of medicine at Walter Reed National Military Medical Center in Washington, D.C. But while she stressed that lifestyle modifications remain the cornerstone of therapy for NAFLD, she also discussed medications that could play a role in treatment.

Among weight loss drugs, orlistat has been found to be helpful in NASH, "but really it's helpful in getting the patients to lose weight," Dr. Torres said. "It's not independently of benefit; it's only as an adjunct." Among incretin mimetics and enhancers, a small pilot trial found exenatide to provide modest weight loss and improvement in hepatic steatosis, with its major side effect being nausea. Larger randomized controlled trials are in progress testing a weekly extended-release formulation, Dr. Torres said. Sitagliptin and vildagliptin, meanwhile, have been found to have a neutral effect on weight loss and have not been studied in NAFLD.

Of diabetic medications, metformin has had mixed results in adult NAFLD, improving hepatic steatosis but yielding no significant improvement in fibrosis and necroinflammation, Dr. Torres said. In contrast, pioglitazone has been well studied in NASH and has been found to decrease insulin resistance and improve hepatic histology, although with modest fibrosis benefit, Dr. Torres said. However, it can also cause weight gain of 5 to 10 pounds over a year of therapy. "That's really a bitter pill to swallow for a patient who you're telling to diet and exercise and lose weight," she said.

Pioglitazone also carries a black-box warning for congestive heart failure and is linked to bone fracture risk in diabetes, and the benefits of the drug are short-lived after therapy is discontinued. "I think it's reasonable to consider if you're struggling with what to give a diabetic NASH patient without heart failure who can tolerate modest weight gain, so it's a lot of caveats," Dr. Torres said.

Vitamin E is guideline-recommended for nondiabetic NASH patients, and it is reasonable to consider 400 to 800 IU once daily in this group, Dr. Torres said. Pentoxifylline is not mentioned in guidelines but is a safe medication and has moderate-quality evidence supporting decreased steatosis, fibrosis, and lobular inflammation, she noted. It can be considered in NASH patients who are not eligible for vitamin E or pioglitazone.

As for statins, Dr. Torres noted that many patients with NAFLD meet treatment guidelines for statin therapy for cardiovascular benefit and that although the drugs may further increase already elevated liver enzymes in these patients, they rarely cause serious liver disease. Guidelines recommend them for dyslipidemia in NASH patients but not specifically to treat NASH, she said.



Breaking news


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Internists talk about MACRA's major impact

ACP convened a panel yesterday to talk about how the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) and the new payment systems in the law will impact physicians and patients.

"ACP was encouraged last week that the proposed rule to implement MACRA makes significant improvements in simplifying the administrative burden and introducing greater flexibility in meeting requirements of quality reporting," said Wayne Riley, MD, MPH, MBA, MACP, president of ACP. "ACP has been a leader in payment reform because we want payments that better align with value, rather than volume of care."

MACRA was passed and signed into law in spring 2015. The law ended the repeated threat of drastic cuts to Medicare physician payments while moving Medicare toward a system of value-based payments. A proposed rule to implement the law was released on April 27.

Members of the panel were Dr. Riley; Bob Doherty, Senior Vice President, Governmental Affairs and Public Policy for ACP; Shari Erickson, ACP's Vice President, Governmental Affairs and Medical Practice; and Robert McLean, MD, FACP, a practicing physician from New Haven, Ct., and the Chair of ACP's Medical Practice and Quality Committee.

The panel discussed why ACP has advocated for payment reform and why they believe the movement from volume-based to value-based payments is the right direction. This included the advocacy efforts that ACP made regarding the law and things that physicians can be doing now to help their practices get ready for the new payment system.

Dr. McLean, who testified about the MACRA law before the House Energy and Commerce Committee, Subcommittee on Health late last month, provided the perspective of the practicing physician. He brought up the overwhelming frustration that physicians already face, citing struggles with electronic health records, complicated regulations, and unhelpful data on clinical metrics. He said if implemented carefully and correctly that MACRA could provide hope of alleviating some physician burnout. He concluded that moving current Medicare quality reporting programs into a single, less burdensome and more flexible Quality Reporting Program will allow physicians to focus more on delivering high-quality care to their patients.

More information can be found online.


.
Guidelines and tools developed for pediatric-to-adult health care transitions initiative

ACP yesterday released guidelines and tools developed to address the gaps that currently exist for the transitions of pediatric patients into adult health care. The toolkit contains disease/condition-specific tools developed by primary care internal medicine and subspecialties to assist physicians in transitioning young adults with chronic diseases/conditions into adult care settings.

"This project fits into ACP's High Value Care Coordination Project, which is part of ACP's broader high-value care initiative," noted ACP's President Wayne J. Riley, MD, MPH, MBA, MACP. "It attempts to help physicians to provide the best possible care to their patients while simultaneously reducing unnecessary costs to the healthcare system."

Dr. Riley introduced the session and explained how it fit into the ACP high-value care initiative. Panelists were Carol Greenlee, MD, FACP, chair of the initiative and co-chair of the Council of Subspecialty Societies; Gregg Talente, MD, FACP, representing the Society of General Internal Medicine; and Patience White, MD, MA, FACP, co-director, Got Transition: The Center for Health Care Transition Improvement, who is also a fellow of the American Academy of Pediatrics.

This effort is under the direction of ACP's Council of Subspecialty Societies (CSS) in collaboration with Got Transition (GT)/Center for Health Care Transition Improvement, Society of General Internal Medicine (SGIM), and Society for Adolescent Health and Medicine (SAHM).

Based on the joint clinical recommendations from the American Academy of Pediatrics, American Academy of Family Physicians, and ACP, Got Transition/Center for Health Care Transition Improvement developed an evidence-informed model, Six Core Elements of Health Care Transitions, which includes free sample tools that clinicians can download and implement in their offices. These core elements were used as a basis for the development of disease-specific tools through the ACP Pediatric to Adult Care Transitions Initiative.

CSS member organizations were asked to provide volunteers to customize 3 tools for patients with a disease/condition of their choosing who would benefit from improved care transitions as an emerging adult. "Subgroups" consisting of adult and pediatric physicians along with appropriate representation from other clinical organizations and patients and family were established to develop the customized tools. The generic tools from the Got Transition Six Core Elements were used as a formatting guide, but subgroups were allowed to adapt tool formats and content to meet the perceived unique needs of their patients, families and clinical teams.

The customized tools were reviewed by the ACP Pediatric to Adult Care Transitions Initiative Steering Committee, consisting of representation from primary and specialty care internal medicine, medicine-pediatrics, adolescent medicine and Got Transition leadership. The tools were also reviewed by the American Academy of Pediatrics (AAP) specialty groups.

"Developing these guidelines and tools is timely," said Dr. Riley. "We didn't have much until these more than 2 dozen groups collaborated on this effort."



For attendees


.
A peek at the Update in Hospital Medicine

John Bulger, DO, MBA, FACP, is admittedly a little bit biased as the co-moderator of the Update in Hospital Medicine. But he advises his colleagues, "if there's one talk you're going to go to, and you're a hospitalist, it should be this one."

Dr. Bulger and moderator Jordan Messler, MD, ACP Member, plan to review the research of 2015 and early 2016 that should have the greatest impact on hospitalist practice during their session today from 11:15 a.m. to 12:45 p.m. in Room 146.

"We had a tough time narrowing our list down," said Dr. Messler, who is medical director of Morton Plant Hospitalists in Clearwater, Fla. "We could probably talk about 40 or 50 articles—there's a lot out there—but we'll probably keep it to 15 or less and really try to get a good analysis of the top 10, and then have a few other bottom-line thoughts."

The pair was waiting until the last minute to select the biggest studies so far of 2016, but they did choose a top 10 of 2015 for the session.

"We try to cover the most common hospital medicine stuff … articles that we think are high level, articles that are hopefully thought-provoking, and articles that are issues that we face as hospitalists commonly," said Dr. Messler.

More specifically, they will cover new findings about pneumonia, including when to use macrolides and steroids. "There's been a low level of evidence around steroid use in pneumonia, and we think there's good evidence now … getting closer to answering that 'Yeah, we should probably use steroids for severe pneumonia,'" said Dr. Messler.

Of course, there will be talk of sepsis, including the disappointments of early goal-directed therapy. "This has and I think will fundamentally change the way that hospitalists look at treating sepsis," said Dr. Bulger, who is chief quality officer for Geisinger Health in Danville, Pa.

The speakers will discuss another intervention now looking less beneficial than previously thought—bridging anticoagulation. "We see a lot of our colleagues use bridging therapy, when [warfarin], for instance, is stopped, and there's good evidence: Don't do that anymore," said Dr. Messler.

"A lot of hospitalists are doing perioperative care, and that is applicable to them," noted Dr. Bulger.

The speakers plan to focus mostly on topics that will be immediately applicable to their hospitalist audience. They will discuss the perennial hospital medicine topics of critical care, end-of-life care, and readmissions, as well as a relatively newer field of research interest—cognitive function in hospitalized patients.

"Some of the research is inspiring. Let's think about this: What can we possibly be doing in the hospital that's leading to future cognitive issues? Let's hope that further research to clarify this question comes about," said Dr. Messler.

Drs. Messler and Bulger hope that some of the literature's inspiration rubs off on their audience. "I always love going to the updates. You feel like you could really just get a lot of good evidence in a short amount of time, and we want to clearly continue that trend," Dr. Messler said.


.
Update in Women's Health to cover breast cancer, osteoporosis, hormone therapy

Several articles and recommendations published in 2015 have the potential to change internists' management of their female patients, said Melissa McNeil, MD, MPH, MACP, chief of the section of women's health and associate chief of the division of general internal medicine at the University of Pittsburgh Medical Center. She and Sarah Tilstra, MD, MS, FACP, who directs Pitt's women's health track as part of its internal medicine residency program, will summarize new evidence in women's health during their Update in Women's Health session today from 4:30 to 5:30 in Room 146.

Drs. McNeil and Tilstra will discuss clinical topics including breast cancer screening and treatment, supplementation for osteoporosis, and new recommendations on the use of hormones in women in their 60s with vasomotor symptoms. "We're really trying to target common issues that will be of clinical significance to anybody seeing women in the primary care setting," Dr. McNeil said.

The session was designed with practicality in mind and incorporates information that internists can immediately implement, she said. Each article will be introduced with a case and a clinical question and will then be reviewed, critiqued, and summarized with a take-home message about its implications.

In creating a session for general internists interested in providing evidence-based care for women, Drs. McNeil and Tilstra chose articles based on the quality of the studies and the strength of the evidence. "For example, 1 of the articles we're going to cover this year is the new American Cancer Society guidelines for breast cancer screening," Dr. McNeil said. "In previous years, the ACS guidelines have diverged a lot from more traditional guidelines. This year, they present wonderful data to support their new guidelines, so they get a lot of attention from us."

In addition to the ACS guidelines, the session will also include articles concerning the overdiagnosis of breast cancer. Recent findings suggest that increased breast cancer screening is linked to an increase in diagnoses but not a decrease in mortality. Another study on screening looked at breast density and the risk for interval cancer. The findings suggest that breast density alone should not prompt supplemental screening, as most women with dense breasts do not appear to be at increased risk for the detection of interval cancer.

Regarding breast cancer treatment, Drs. McNeil and Tilstra will review an article about the prognosis and treatment of ductal carcinoma in situ suggesting that clinicians may want to reconsider aggressive treatment of this condition.

The session will also cover 2 systematic reviews on calcium supplementation for reducing fractures and increasing bone mineral density. Results of the analyses challenge recommendations that encourage universal calcium supplementation, according to Drs. McNeil and Tilstra. Another study calls the treatment of vitamin D insufficiency into question, observing no difference between high- and low-dose cholecalciferol supplementation in terms of total fractional calcium absorption, bone mineral density, and muscle fitness, they noted.

The talk will conclude with a discussion of a North American Menopause Society statement about extending the safe use of hormone therapy past age 65 in appropriate patients. The statement maintains that clinicians treating healthy women ages 60 and older for moderate to severe vasomotor symptoms or osteoporosis may choose to continue hormone therapy at the lowest effective dose, weighing the risks and benefits of the decision with individual patients.





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