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


Internal Medicine Meeting 2016 News

Scientific Meeting News for May 7, 2016


How to manage sinusitis, CAP in outpatients

Patients with common outpatient infections such as sinusitis and community-acquired pneumonia (CAP) seek relief, which requires a little detective work from the internist to determine potential causes before offering a cure. More...

Hard data lacking on postdischarge follow-up

The literature on postdischarge clinics has traditionally been complicated because patients who visit them are not random. More...

Reducing the discomfort of end-of-life conversations

The ask-tell-ask model for end-of-life conversations starts with questions, instead of statements. More...

Breaking news

More changes for MOC in the works

On Thursday, the American Board of Internal Medicine (ABIM) announced plans to change its Maintenance of Certification (MOC) program to allow shorter, more frequent assessments. More...

ACP unveils toolkit to help doctors combat climate change

The toolkit will help health care professionals engage in environmentally sustainable practices that reduce carbon emissions, educate their colleagues and community about the health risks posed by climate change, and advocate for a low-greenhouse gas emission health care sector. More...

ACP holds briefing on policy priorities

ACP's President and President-elect reviewed ACP's policy achievements of the last year and previewed College policy priorities for the next year. More...

For attendees

Update in Geriatric Medicine to highlight highly anticipated research

David B. Reuben, MD, FACP, cast a wide net when selecting articles to cover in this year's Update in Geriatric Medicine, which will be held today from 9:30-10:30 in Room 146. More...

ACP Annual Business Meeting to be held today

All members are encouraged to attend ACP's Annual Business Meeting to be held today. Current College Officers will retire from office, and incoming Officers and new Regents and Governors will be introduced. More...


How to manage sinusitis, CAP in outpatients

Patients with common outpatient infections such as sinusitis and community-acquired pneumonia (CAP) seek relief, which requires a little detective work from the internist to determine potential causes before offering a cure. George C. Mejicano, MD, MS, FACP, offered tips and tricks on how to appropriately manage these and other infections during his Friday session.

Most sinusitis cases diagnosed in the outpatient setting are typically caused by uncomplicated viral upper respiratory infections, said Dr. Mejicano, professor of medicine and senior associate dean for education at Oregon Health & Science University. Features that predict sinusitis are maxillary toothache, purulent secretion by exam, poor response to decongestants, abnormal sinus transillumination, and history of colored nasal discharge, Dr. Mejicano said.

An opaque result from sinus transillumination correlates very well with positive sinus aspirates, Dr. Mejicano said. "Most of us don't do this clinically, but if you want to go back and be a little bit old-school, this is a trick you might want to look at," he said. Sinus radiography is not recommended for diagnosis in routine cases because scans may be too sensitive, Dr. Mejicano said.

Only about 0.5% to 2% of patients see their common colds progress to acute bacterial sinusitis, he noted, but there's a problem with diagnosis. "It turns out that most of us are actually not very good at diagnosing bacterial rhinosinusitis," said Dr. Mejicano. This is because bacterial and viral sinusitis are difficult to distinguish on clinical grounds, he added.

Internists should watch out for "double sickening," or worsening of symptoms after a period of initial improvement, as most people with the common cold experience their worst symptoms on either the second or third day of illness before rebounding, he said. If symptoms start to worsen beyond those first couple days, that is a "very important sign" that may suggest a bacterial infection, Dr. Mejicano said. The other most useful signs and symptoms of bacterial sinusitis include purulent nasal discharge, maxillary tooth pain or facial pain (especially unilateral), and unilateral maxillary sinus tenderness, he said.

In the medical management of sinusitis, steam and saline relieve symptoms by preventing crusting and liquefying secretions, and decongestants help to increase ostial diameter, although rebound congestion is a concern, Dr. Mejicano said. Acute sinusitis resolves without antimicrobial treatment in most cases, he said. Antibiotics eradicate bacterial infection, but there are conflicting data on their efficacy for treating bacterial sinusitis. "They do have some benefits … but the placebo effect is quite big—over 40%," Dr. Mejicano said.

Symptomatic treatment is the preferred initial therapy for sinusitis, but patients who should receive antibiotics are those with 3 to 4 days of severe symptoms (e.g., fever, purulent drainage, facial pain), worsening symptoms after initial improvement, or lack of improvement after 10 days, according to 2012 Infectious Diseases Society of America (IDSA) guidelines.

When needed, amoxicillin-clavulanate and doxycycline are recommended as first-line antibiotics, typically given for 5 to 7 days in adults, Dr. Mejicano said. But try not to limit therapy to antibiotics. "Bacterial sinusitis is really an abscess in your head, and so what you should think about is not only treating the infection but also draining the abscess. That means opening up [the] ostium," said Dr. Mejicano.

Older patients are at the highest risk of CAP, which is "a very big problem, and we need to be better at treating it," Dr. Mejicano said. IDSA guidelines issued in 2007 note that radiography or other imaging is required for a CAP diagnosis, although a sputum sample and other routine diagnostic tests to identify an etiologic diagnosis are optional.

"I don't know the best time to get an X-ray relative to symptom onset. However, if you're going to say they have pneumonia, you really should get a film," Dr. Mejicano said, although he does not recommend follow-up imaging. He added that most of the time in the outpatient setting, not a lot of tests are needed.

Although Streptococcus pneumoniae is the No. 1 cause of CAP in the U.S., this changes in the summer months, when atypical Mycoplasma pneumoniae becomes the more common cause, Dr. Mejicano said. "So if you have a patient with CAP in August, it's actually more likely Mycoplasma and not pneumococcus, so just keep that in mind," he said.

In 98% of decisions regarding CAP management, the initial assessment of severity drives treatment, Dr. Mejicano added. "It's both science and art," he said, as initial assessments should be based on a severity-of-illness score (e.g., CURB-65) and clinical judgment by the physician (e.g., determining ability to take oral medications). The CURB-65 factors in confusion, uremia, respirations, blood pressure, and age to calculate mortality risk and recommend a site of care. Scores of 0 and 1 correspond to outpatient treatment, a score of 2 means treatment in an inpatient ward, and scores from 3 to 5 necessitate ICU care.

IDSA guidelines on drug choice and duration suggest using a macrolide (erythromycin, azithromycin, or clarithromycin) or doxycycline, based on strong and weak levels of evidence, respectively. For patients with chronic lung, heart, liver, or renal disease; alcoholism; no spleen; malignancies; immunosuppression; or use of antibiotics within the past 3 months, guidelines strongly recommend respiratory fluoroquinolone or beta-lactam plus a macrolide.

Dr. Mejicano said his personal and guideline-based recommendations are doxycycline in outpatients with mild CAP; azithromycin and high-dose amoxicillin in outpatients with moderate CAP who have recently taken antibiotics; and azithromycin and cefuroxime in outpatients with moderate CAP and comorbidities. For ward inpatients with moderate CAP, he recommends IV ceftriaxone and IV azithromycin before starting oral cefuroxime and oral azithromycin. For ICU patients with severe CAP, he suggests cefepime and ciprofloxacin.

The minimum duration of treatment for CAP is 5 days, and there should be no fevers for 2 to 3 days, Dr. Mejicano said. "You want to make sure … they're well enough to adhere to [the treatment regimen]," he said.

Hard data lacking on postdischarge follow-up

Don't call Jeffrey Greenwald, MD, "the readmissions guy."

"That sits like a lump in my throat," he said Friday morning at Internal Medicine Meeting 2016.

"I'm not a readmissions guy. I'm a care transitions guy."

To that end, at his session, "The Evolving Role of Hospitalists in Care Transitions," Dr. Greenwald, who is an associate professor of medicine at Harvard Medical School and Massachusetts General Hospital in Boston, offered attendees a hard look at the data on a specific area of care transitions: postdischarge follow-up.

A study published in the Journal of General Internal Medicine in 1996 found a statistically significant reduction in ED visits in patients who visited a postdischarge clinic versus those who did not, but no significant differences in 30-day readmissions, length of stay, or mortality, Dr. Greenwald said. A more recent study published by the Journal of Hospital Medicine in 2014 looked at a composite of readmissions, ED visits, and mortality in recently discharged patients who had a postdischarge visit at an urgent care clinic, their primary care physician, or a hospitalist-run postdischarge clinic. No improvements were seen with the postdischarge clinic over the other locations. Readmissions were highest in the postdischarge clinic group, and no differences were seen in ED visits or mortality.

"Their primary outcome was negative. They couldn't demonstrate a benefit," Dr. Greenwald said. "At best, it was a wash."

Dr. Greenwald pointed out that the literature on postdischarge clinics has traditionally been complicated because patients are not randomly assigned; they go there because they can't get into a primary care clinic. "They're not random. They may be sicker, they may be poorer, they may be older, they may be more complicated, they may be … underserved … whatever the issue is, these are not apples-to-apples comparisons," he said.

He listed the results of his own nonscientific survey of postdischarge clinics, noting that of the 15 he was familiar with, 40% have shut down. "They've shut down because they're not financially viable, they didn't have enough patients to go to them, there were some conflicts with primary care practices around them, etc.," Dr. Greenwald said. "The point is at the end of the day a lot of these, which sounded initially like really good options, failed."

Regarding postdischarge appointments, Dr. Greenwald discussed a study published in the Journal of the American Medical Association in 2010 of the relationship between early physician follow-up and 30-day readmission among approximately 300,000 Medicare beneficiaries hospitalized for heart failure. The study assessed hospital-level follow-up rates for 7-day postdischarge appointments by quartile and found that while the lowest quartile had the highest readmission rate, there was no difference among the other 3 quartiles.

Some evidence does suggest that medically complex younger patients may benefit from postdischarge visits, however, Dr. Greenwald said. While a study published in Medicare Medicaid Research Review in 2014 found no effect of postdischarge visits on Medicare patients' readmissions, a study published in Annals of Family Medicine in 2015 noted that expedited follow-up within 7 days seemed to benefit Medicaid patients who were at higher risk for readmission based on comorbid conditions.

Postdischarge phone calls are also lacking definitive evidence support, according to Dr. Greenwald. He pointed to a review done in 2009 by the Cochrane Collaboration looking at hospital-based telephone follow-up after discharge.

"They couldn't find any evidence of an admission reduction. But is anybody surprised?" Dr. Greenwald said. "There are almost no studies where you do 1 thing and it changes readmission rates. You have to bubble wrap patients in lots of interventions if you're going to change readmission rates."

A retrospective study published in Population Health Management in 2011, meanwhile, looked at the impact of a postdischarge telephone follow-up call from a nurse in the first 14 days after discharge on 30-day readmission rates. The peak readmission day was day 2 or 3, and Dr. Greenwald noted that this has been seen in other trials as well. The study found that patients who didn't receive a postdischarge call had a 30% higher readmission rate.

Dr. Greenwald stressed that this is at best an association, since causality can't be proved in this type of trial, and noted that his key takeaway from the study was the peak days for readmissions and what that means for the optimal timing of postdischarge calls.

"I take to heart the day 2 lesson," he said. "Don't wait until day 14. The horse is out of the barn."

Reducing the discomfort of end-of-life conversations

During her Friday morning session on end of life and palliative care, Janet Abrahm, MD, FACP, had attendees role play a conversation between a doctor and a terminally ill patient.

Then she asked them how it went: "How many of you felt like you needed to go out and beat your head against the wall?"

To make this crucial task a little less painful for everyone involved, Dr. Abrahm, who is a palliative care physician and professor at Harvard Medical School in Boston, proposed a new model of patient and family conversations.

She calls the model ask-tell-ask, and it's different from the typical conversation because it starts with questions, instead of statements. "Usually doctors [talking to families] start with, 'This is her situation …'," Dr. Abrahm said. Instead, start with questions like "How do you think you [or the patient] are doing?" and "What changes have you seen in the last days, weeks, months?"

Then comes the really crucial question: "What are you hoping for?" And don't ask it just once, Dr. Abrahm advised. "Keep going with that. Keep asking the son, 'What are you hoping for? And what else? And what else?'"

This question gets at the central conflict in end-of-life discussions. "What makes the conversation difficult is the gap between reality and what they know or hope for," Dr. Abrahm said. The time to shrink that gap is in the second or "tell" part of the conversation.

Physicians should explain why "doing everything" would do more harm than good and offer assurance that the patient will be kept comfortable. "Then I stop talking," said Dr. Abrahm, noting that she leaves at least 10 seconds of silence. "If you're that son who's been told that everything he hopes for won't happen, you need time to go down and come back," she said.

Then comes more asking, including what you can do to help immediately. "Someone said to me, 'I can't drive home. Who's going to pick up the kids from school?'" Dr. Abrahm said. In addition to offering practical help, ask whether the patient or family would like you to talk to, or attend a conversation with, anyone else in the family.

For physicians who want even more specific advice on these kinds of conversations, she recommended serious illness conversation resources developed by Rachelle Bernacki, MD, and Susan Block, MD, including a 2014 paper for the ACP High Value Care Task Force. "If you want some sentences that patients don't seem to be upset by and help us further this conversation, that's what this is," said Dr. Abrahm. They offer specific questions and statements through conversational steps of setup, assess, share, explore, and close.

Once you have closed the conversation, remember 1 more detail that may make the whole thing a little less painful. If the patient was either involved in the conversation or asked you to speak with family members, you can bill for it. "As often as you need to have this conversation, you can bill for it. If you need multiple conversations, you can bill for multiple conversations," said Dr. Abrahm.

Breaking news

More changes for MOC in the works

On Thursday, the American Board of Internal Medicine (ABIM) announced plans to change its Maintenance of Certification (MOC) program to allow shorter, more frequent assessments, among other details outlined by ABIM representatives during a session at Internal Medicine Meeting 2016.

The new form of assessment will become an option starting in 2018. "The idea behind this is that physicians who perform above an expected level of performance will test out of the longer-form 10-year assessment," Richard Baron, MD, MACP, president and CEO of ABIM, said during the Thursday session.

The 10-year assessment will remain an option but will also undergo changes. "It will look different in a variety of ways from what we're doing now," said Dr. Baron.

One possible difference is that both kinds of assessment could go open-book. ABIM is conducting a pilot study of this concept with 850 physicians. "We don't know what happens when you make the book available," said Dr. Baron. That setup could better simulate real-world practice but also cause problems of its own, he noted, offering an example of the latter: "Do people look up every question and run out of time?"

Other considerations include how often these less frequent exams will need to be completed, how many questions they'll have, and how they might be given remotely but securely. "What we need to do is get people's thoughts and comments," said Dr. Baron.

ACP EVP and CEO Steven Weinberger, MD, MACP, offered an initial comment on the proposed changes. "ACP is encouraged to hear that ABIM is considering alternatives to the 10-year secure examination for Maintenance of Certification and that they are beginning to respond to the concerns we've raised on behalf of our members," he said. "The specifics of how the new approach is designed and implemented will be critical to its success in decreasing the burden and increasing the relevance of the current program."

The ABIM announcement promised greater specifics on the new assessment system by the end of 2016. Physicians who recertify in 2016 and 2017 will have to do so under the 10-year system, but their exams will also see some changes.

The MOC exam has been updated to be less like initial board certification and more focused on conditions and issues physicians actually face in practice, Patricia M. Conolly, MD, FACP, chair-elect of ABIM, said during the Thursday afternoon session. "The feedback that we have so far on the new exam is that it is far more relevant," she said.

Starting now, physicians are also getting more specific feedback with their exam scores, including comparisons to the performance of other test-takers.

During the session, ABIM representatives also addressed other complaints they've received from diplomates in recent years. "The board hears you and we know that there's a lot of frustration, anger, [and] concern, and many of you have questions," said Yul Ejnes, MD, MACP, former Chair of ACP's Board of Regents and member of the internal medicine subspecialty board.

Recent responses by ABIM have included freezing exam fees, providing the Board's financial information online, collaborating with CME providers, eliminating some components of MOC, adding a 1-year grace period for those who fail recertification, and changing terminology from "meeting requirements" to "participating in MOC," Dr. Conolly reported.

"There's no question that any way we do this, there are challenges to doing it right and it's going to take attention. If we closed tomorrow, doctors would still be spending a lot of time staying current in knowledge and practice," said Dr. Baron. "We want to be able to make a statement that someone is staying current in knowledge and have a basis for that statement. We all have an interest in there being a real standard."

ACP unveils toolkit to help doctors combat climate change

ACP unveiled a toolkit to help internists and other doctors advocate for effective climate change adaptation and mitigation policies.

"Taking action on climate change creates a 'win-win' situation because it benefits public and individual health," said ACP President Wayne J. Riley, MD, MPH, MBA, MACP, at Internal Medicine Meting 2016. "ACP's climate change toolkit is a resource for doctors and other health care professionals to use to engage in environmentally sustainable practices that reduce carbon emissions, educate their colleagues and community about the health risks posed by climate change, and advocate for a low-greenhouse gas emission health care sector."

ACP cites higher rates of respiratory and heat-related illnesses, increased prevalence of diseases passed by insects, water-borne diseases, food and water insecurity and malnutrition, and behavioral health problems as potential health effects of climate change. The elderly, children, people with chronic illnesses, and the poor are especially vulnerable.

The toolkit for doctors includes:

  • An introduction to the Action Plan that briefly explains why this initiative is necessary and summarizes the materials and resources to help members become familiar with the evidence and science about the reality of climate change and its effect on health.
  • Customizable slides for presentations to medical students, colleagues, and hospital administrators. The presentation explains how climate change affects health, mitigation and adaptation strategies, and how the health care sector can become more environmentally sustainable.
  • Information about how to facilitate, organize, and lead efforts to reduce the impact of physician offices, hospitals, and other health care facilities on climate change.
  • Talking points about how climate change impacts health and the benefits to public and individual health by taking action now. By objectively informing their communities about the human health threat posed by climate change, physicians can help depoliticize the issue and encourage cooperation to tackle climate change.
  • A multi-document resource, "Greening the Health Care Sector," that explains how the health care sector contributes to greenhouse gas emissions and what can be done to curb impact. From how small practices can "go green" to mitigation focus areas like energy efficiency, transportation, and building structures, each document includes a "case study" and additional resources on the topic.
  • A Patient FACTS piece on climate change developed by ACP's Center for Patient Partnership in Healthcare. Part of ACP's patient-tested educational series designed to help patients increase their understanding of health issues, Patient FACTS also lists relevant questions that patients can ask to facilitate communication with their doctor.

In a position paper on climate change and health, published by Annals of Internal Medicine on April 19, ACP warned that climate change will have devastating consequences for public and individual health unless aggressive, global action is taken now to curb greenhouse gas emissions.

By increasing energy efficiency and using renewable energy sources, the EPA estimates that 30% of the health care sector's energy use could be reduced without compromising care quality.

"The health care sector consumes a massive amount of energy, ranking second-highest in energy use after the food industry, spending about $9 billion annually on energy costs," Dr. Riley said. "ACP encourages physicians, both individually and collectively, to adopt lifestyle changes that reduce environmental impact and to increase the environmental sustainability of their practice and the broader health system in which they work."

ACP holds briefing on policy priorities

ACP President Wayne J. Riley, MD, MPH, MBA, MACP, and President-elect Nitin S. Damle, MD, FACP, held a press briefing Friday afternoon to review ACP policy achievements of the last year and to preview College policy priorities for the next year.

"The past year has been extremely busy on both the legislative and regulatory fronts, and next year looks to be the same," said Dr. Riley, "especially given the many variables that can impact government and health care."

Dr. Riley noted that last week's release of the MACRA-implementation proposed rule was just the latest in a series of significant changes to health care and its reimbursement structure over the past year.

Physicians, and internists in particular, rejoiced last April with the passage of MACRA and the repeal of the sustainable growth rate (SGR) formula. ACP advocated for a long-term fix that would move physician payments away from incentivizing volume of care toward payments that would focus on the value of care provided. Many of ACP's ideas found their way into MACRA, which was passed with bipartisan support in both the House and Senate.

"MACRA will now provide a stable payment environment for physicians moving forward as we begin the transition toward a system focused on quality of care," Dr. Riley said. "Now ACP's advocacy moves toward ensuring that this new law is implemented as smoothly as possible for physicians."

The creation of new codes for internists' services means increased reimbursements. These include chronic care management codes, new advanced care planning codes, and changes to the transitional care management code.

ACP lobbied for and was relieved when funding was preserved for the Agency for Health Research and Quality (AHRQ). Also, funding for the National Health Service Corps (NHSC), which had been set to expire on Oct. 1, 2015, was extended. NHSC is vital to providing primary health care to underserved communities and training a new generation of primary care physicians.

"Finally," said Dr. Riley, "last June, the Supreme Court of the United States issued its ruling that the insurance premium subsidies that are part of the Affordable Care Act will continue to be available in states where the federal government manages their health insurance marketplace. ACP has a long history of supporting efforts to extend health insurance coverage to all. We believe that eliminating the subsidies to purchase insurance in states with federally run exchanges would have led many to drop coverage or elect to go uninsured, not only endangering their own health, but driving up the health insurance premiums for those who did remain covered."

Dr. Damle reviewed the following as part of ACP's policy agenda for the coming year:

  • ACP will advocate for members of Congress to introduce and enact chronic care legislation, currently under development in the Senate Finance Committee.
  • ACP supports the HELP committee's ongoing efforts to develop and advance comprehensive health IT reforms. As the full Senate prepares to consider the Improving Health Information Technology Act, ACP recommends that (at a minimum) improvements be added and that the House develop similar companion legislation.
  • ACP will urge the Senate Finance Committee to develop legislation that will eliminate payment and regulatory barriers to telemedicine in ways that support the patient-physician relationship.
  • ACP will advocate for measures to strengthen insurance companies' compliance with existing mental health parity laws as well as elements necessary to integrate behavioral and mental health into the primary care setting and reduce barriers associated with such disorders.
  • ACP will urge House members to pass the Comprehensive Addiction and Recovery Act, legislation that provides grant funding for efforts to mitigate and stem the growing problem of opioid and substance abuse disorders in this country.
  • ACP will lobby members of Congress to introduce and seek enactment of legislation to address the rising cost of prescription drugs.
  • ACP will call for members of Congress to develop legislation to reform graduate medical education to prioritize funding toward physician specialties facing shortages, including primary care internal medicine; to improve transparency; and to ensure sustainable and broadly supported funding by all payers going forward.

For attendees

Update in Geriatric Medicine to highlight highly anticipated research

David B. Reuben, MD, FACP, cast a wide net when selecting articles to cover in this year's Update in Geriatric Medicine, which will be held today from 9:30-10:30 in Room 146.

"I tried to select articles that general internists would want as well as geriatricians," said Dr. Reuben, who is chief of the division of geriatrics and a professor of medicine at the University of California, Los Angeles. "Also, there were a number of clinical trials that were published over this past year, things that we've been waiting for for a number of years."

One of those trials, of course, was SPRINT, the Systolic Blood Pressure Intervention Trial, which was published in the Nov. 26, 2015, New England Journal of Medicine and compared lowering systolic blood pressure to a goal of 120 mm Hg versus 140 mm Hg among patients at high risk for cardiovascular events. "One of the nice things about this was that it oversampled people 75 years of age and older," Dr. Reuben pointed out.

The trial showed that the lower blood pressure goal appeared to reduce cardiovascular events in the studied patients, at least as much among elderly patients as among younger ones, he noted. However, Dr. Reuben said, "The big caveat here is that there are a lot of exclusionary criteria, so what that meant was that a lot of older people that we would see in our practices wouldn't have been eligible for this treatment."

Dr. Reuben will also discuss 3 studies published in 2015 that looked at prevention of cognitive decline, which he called "really a hot topic right now." A substudy of AREDS2 (Age-Related Eye Disease Study 2) that was published in the Aug 25, 2015, JAMA looked at whether omega-3 long-chain polyunsaturated fatty acids and antioxidant supplements protect against cognitive decline, while the LIFE (Lifestyle Interventions and Independence for Elders) randomized trial, which appeared in the same issue, compared a 24-month physical activity intervention with health education in sedentary older adults. Both of these trials had negative results.

However, FINGER (Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability), a 2-year trial published by The Lancet on March 11, 2015, found that a multifactorial intervention aimed at risk factors for cognitive decline appeared to lead to better outcomes. The take-home message of these 3 trials, Dr. Reuben said, is that "dietary supplementation with polyunsaturated fatty acids, antioxidants, beta-carotene didn't prevent cognitive decline … nor did moderate-intensity physical activity alone, but when multiple risk factors were addressed, there were some aspects of cognition that did improve."

Dr. Reuben chose another study to cover in part because "it flew in the face of a paradigm and emerging treatment trend," he said. This observational study done in Europe and published in the Oct. 29, 2015, New England Journal of Medicine looked at excess mortality in type 2 diabetes and found that as people got older, the condition conferred a survival advantage compared with younger people. This was particularly true if patients had no kidney damage and if their diabetes was fairly well controlled, Dr. Reuben noted. "There's a lot of pressure to start treating diabetes earlier and more aggressively in older people, and this study suggests maybe that's not necessary to do," he said.

In the area of orthopedics, Dr. Reuben will discuss a study published in the Oct. 22, 2015, New England Journal of Medicine comparing total knee replacement with nonsurgical treatment and a study published in the April 7, 2015, Annals of Internal Medicine comparing surgical versus medical intervention for lumbar spinal stenosis. In the former study, Dr. Reuben said, knee replacement surgery led to better outcomes, but with more serious adverse effects. "If you're willing to bear the price, then in fact you do get better outcomes on things such as pain, function, and quality of life," he said.

For lumbar spinal stenosis, meanwhile, surgery and physical therapy appeared to be equally beneficial, but half of the patients who were assigned to physical therapy crossed over to the surgical intervention, Dr. Reuben said. "If you can get people to hang in there, [physical therapy works,] but most people aren't [willing]," he said. "Most people are going to opt for the surgery."

Dr. Reuben will also cover several studies on medications in geriatric patients, including novel oral anticoagulants, statins, antihypertensive drugs, and testosterone therapy, as well as a trial published online Sept. 7, 2015, by the Archives of Physical Activity and Rehabilitation that compared the use of a Wii Fit training device to conventional balance training in 60 nursing home residents with a history of falls. At the end of the intervention, those in the Wii group had greater muscle strength, faster reaction time, less body sway, a better score on a measure of composite fall risk, and 69% fewer falls over 1 year compared to conventional balance training.

"What's cool about this is [patients] can do it on their own, and it's a game," Dr. Reuben said. "It's a very small study, it needs replication, but it's fun to expand our thinking."

ACP Annual Business Meeting to be held today

All members are encouraged to attend ACP's Annual Business Meeting to be held today. Current College Officers will retire from office, and incoming Officers and new Regents and Governors will be introduced.

The meeting will be held in Room 207A today from 12:45 to 1:45 p.m., with ACP President Wayne J. Riley, MD, MPH, MBA, MACP, presiding.

Robert A. Gluckman, MD, MACP, will present the Annual Report of the Treasurer. A key feature of the meeting is the presentation of ACP's priorities for 2016-2017 by Executive Vice President and Chief Executive Officer Steven E. Weinberger, MD, MACP. Members will have the opportunity to ask questions following Dr. Weinberger's presentation.

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