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

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Internal Medicine 2014 News



Scientific Meeting News for April 10, 2014




Highlights

Emphasize exercise for CAD testing, disease prevention

Sex can be a great motivator when it comes to getting chronic coronary artery disease (CAD) patients to take an exercise stress test, said Steve Kopecky, MD, during a talk on chronic CAD at the Cardiology for the Internist precourse on Wednesday. More...

GERD can be easier to diagnose, less expensive to manage

It's possible to diagnose and treat gastroesophageal reflux disease (GERD) without spending a lot of money, Seth Gross, MD, reassured attendees at Wednesday's precourse on gastroenterology. More...


Breaking news

ACP unveils tools for rheumatoid arthritis, chronic pain, irritable bowel syndrome, exocrine pancreatic insufficiency

ACP is releasing a series of educational materials to help patients and physicians manage rheumatoid arthritis, chronic pain, irritable bowel syndrome, and exocrine pancreatic insufficiency. More...


For attendees

Physician/journalist to deliver keynote address

Elisabeth L. Rosenthal, MD, a New York Times senior writer, will deliver the keynote address at the Opening Ceremony of Internal Medicine 2014. She will speak about "Price: A Side Effect Doctors Can't Ignore" in Hall D2 from 9:30 to 10:30 a.m. More...

On Being a Doctor book signing takes place today

The editors of On Being a Doctor, volume 4, Michael A. LaCombe, MD, MACP, and Christine Laine, MD, FACP, will be at the Annals of Internal Medicine booth in the ACP Resource Center today from 10:30 a.m. to 12:00 p.m. to sign copies of their new book. More...

Meet the Consult Guys

Stop by the Annals of Internal Medicine booth today to meet The Consult Guys! More...

It's not too late to submit a profile to the ACP Job Placement Center

Looking for a job? ACP's Job Placement Center offers career opportunities during Internal Medicine 2014. Submit a Job Seeker's Profile (mini-CV) to be included in 1 of 2 booklets based on your criteria. Your profile is guaranteed to be distributed to participating employers who submit a job posting to the center. You do not have to attend the meeting to submit a profile. More...


Highlights


.
Emphasize exercise for CAD testing, disease prevention

Sex can be a great motivator when it comes to getting chronic coronary artery disease (CAD) patients to take an exercise stress test, said Steve Kopecky, MD, during a talk on chronic CAD at the Cardiology for the Internist precourse on Wednesday.

"We often have patients come in and say they want us to tell their spouses that it's OK to have intercourse," said Dr. Kopecky, a professor of medicine in the division of cardiovascular diseases at Mayo Clinic in Rochester, Minn. "The test is helpful for showing patients it's OK to exercise."

Indeed, he said, the exercise stress test has many advantages as a diagnostic and risk stratification tool for chronic CAD patients who are able to go 5 metabolic equivalents (METS), which is about 2 flights of stairs or 2 blocks (walked vigorously).

For one, exercise stress testing offers more information than pharmacologic stress testing because the inability to exercise in and of itself is associated with increased cardiovascular risk, he said. "The reason for not being able to exercise could be a bad foot, but still, the inability itself increases the risk," he said.

Also, exercise capacity is the single most powerful predictor of cardiovascular events, regardless of whether symptoms are present. "It's more predictive than blood pressure, chest pain, an echo and ST-segment deviations," he said.

Ischemia at a low workload indicates a greater likelihood of severe disease and a worse prognosis than does the same degree of ischemia at a high workload, he noted. "Using an exercise stress test documents the workload that induces ischemia, so you have a benchmark exercise level you can tell the patient," he said.

Another advantage of the exercise stress test is that it is nearly as accurate as an imaging stress test for correctly identifying patients with left main or 3-vessel CAD and for predicting outcomes. "The higher sensitivity of the imaging stress [test] is due to detection of more patients with 1- or 2-vessel disease," he said.

As for exercise testing after revascularization, it is useful for determining the immediate result of the revascularization, but keep in mind the optimal effects aren't typically seen until about 6 weeks after the procedure, Dr. Kopecky said. At 6 months or more after revascularization, exercise testing can be used to help in evaluation and treatment and in guiding the best cardiac rehabilitation program and return-to-work plans, he said.

Patients unable to exercise for 5 METS can do pharmacologic stress testing, the choice of which will depend on the patient's profile. For asthma and heart block patients, dobutamine is fine, but adenosine and dipyridamole will exacerbate the asthma and heart block. On the other hand, dobutamine is relatively contraindicated for patients with poor control of hypertension, recent transient ischemic attacks (TIAs), or glaucoma and those who are on high-dose beta-blockers, he said.

Stress cardiac imaging tests are often overused and are a huge target for professional societies like ACP and the American College of Cardiology, as well as the American Board of Internal Medicine's Choosing Wisely campaign, Dr. Kopecky noted. "We really, really overdo them."

For example, the American College of Cardiology advises against stress imaging in initial evaluation of patients without cardiovascular symptoms (except high-risk patients); annual stress imaging as routine in asymptomatic patients; and stress imaging preoperatively in low-risk patients undergoing noncardiovascular surgery.

The American Society of Nuclear Cardiology, meanwhile, says not to perform stress imaging or coronary angiography in patients without symptoms unless they are high risk; advises against cardiovascular imaging in low-risk patients; and says not to use cardiovascular imaging preoperatively in intermediate- or low-risk noncardiovascular surgery patients, he noted.

However, stress imaging does have advantages with certain conditions, including left bundle-branch block, Wolff-Parkinson-White syndrome, paced rhythm, left ventricular hypertrophy with strain, digoxin therapy, a >1-mm ST-segment depression at rest, and history of coronary revascularization. In these situations, imaging can "add accuracy, localize ischemia, measure [left ventricular ejection fraction], and provide useful information when combined with stress testing," he said.

Dr. Kopecky also promoted exercise for chronic CAD patients—really, all patients—in a different sort of setting: as secondary prevention. Only 22% of U.S. adults exercise the recommended amount of more than 150 minutes per week, he noted.

"I find it helps if I tell my patients to think of exercise as 'vigorous leisure activity,'" he said. "And for those who say they don't have time, remind them that if you don't exercise, you'll have to find time later for disease."

Even low-level physical activity is helpful, he added. Fifteen minutes of exercise per day 6 days a week reduces cardiovascular mortality by 20%, with the benefits increasing with more exercise. "The health benefits are seen immediately, and the mortality benefits are seen within 2 years," he said.

Meanwhile, cardiovascular mortality risk starts to decrease with just 10 minutes of vigorous activity 3 times per week, he added. At 1,080 exercise calories per week, cardiovascular death risk is lowered by 75%, he said.

The most effective aerobic training incorporates interval training, where rather than maintaining a continuously elevated heart rate at, for example, 120 beats per minute (bpm), the patient aims to reach a heart rate of 140 bpm for intervals of 30 to 120 seconds, then dip down to 110 to 120 bpm, then ramp back up to 140 bpm over a period of 30 minutes, Dr. Kopecky said.

"The benefits of using intervals include that they raise HDL cholesterol more [than continuous-rate exercise]; lower LDL cholesterol particle counts more; use more calories; promote more blood vessel dilation; and lead to better fitness and less boredom," he said.


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GERD can be easier to diagnose, less expensive to manage

It's possible to diagnose and treat gastroesophageal reflux disease (GERD) without spending a lot of money, Seth Gross, MD, reassured attendees at Wednesday's precourse on gastroenterology.

"Many times we can make the diagnosis of gastroesophageal reflux disease just in the office," said Dr. Gross, an assistant professor of medicine in the division of gastroenterology at New York University. "With a cost-conscious approach, we're going to really try to minimize how often we use endoscopy."

The diagnostic process usually begins when a patient presents with symptoms. Most of us are personally familiar with the most common symptoms of heartburn and regurgitation. "Everybody gets physiologic reflux, where after you eat a heavy meal, you may have some symptoms but they're not persistent," said Dr. Gross. GERD can also present as chest pain, in which case "you always want to make sure there's not an underlying cardiac disease," Dr. Gross said.

Some patients can be trickier, presenting with extraesophageal symptoms. "There's laryngitis, throat clearing, asthma, globus … sometimes this is the only symptom," he said.

Such cases initially may lead patients to the wrong specialist and testing. "When a patient has a chronic cough or throat clearing with globus, they'll go to the ear, nose, and throat physician, they'll have a laryngoscopy and they'll see some irritation or inflammation … and the patient's told that they have acid reflux," said Dr. Gross.

That diagnosis is not necessarily correct. "Laryngoscopies in regular healthy individuals have findings that you would see with patients with gastroesophageal reflux disease," he said. "The diagnosis of GERD based on a laryngoscopy for pharyngitis is definitely not enough."

A medication trial, with proton-pump inhibitors (PPIs), should usually be the diagnostic strategy for GERD. "If someone doesn't have alarm symptoms, and you're not concerned that they have an underlying cardiac condition, a simple trial of empiric PPIs could be very effective. It can confirm the diagnosis and establish GERD and lead to a treatment to make your patient feel much better," said Dr. Gross. Alarm symptoms include difficulty swallowing, unintentional weight loss, vomiting, and blood, and they indicate a need for endoscopy.

There are a number of tests that assess the state of the esophagus, but they are not typically appropriate for diagnosing GERD. "All these tests, they all come with a cost. It's important to put that into perspective when we're seeing our patients," said Dr. Gross.

He presented a chart of the costs of various diagnostic methods, ranging from $17 a month for an inexpensive PPI to $1,500 for ambulatory reflux monitoring, up to $2,300 to $3,500 for an endoscopy or esophageal biopsy, depending on whether it's performed in an office or hospital. Some other expensive options—barium swallow tests and manometry—should definitely not be used to diagnose GERD, he noted.

If a medication trial is unsuccessful, verify that the patient followed the proper protocol. "[Mistakes include] they'll take it when heartburn starts. They'll take [it] in between meals. We know that the way that these medications work best is if they take them 30 to 60 minutes prior to the meal, and ideally, the first meal of the day," said Dr. Gross. If treatment still doesn't work, you may try a different PPI (although all have the same mechanism of action) or increase in dose.

A few patients may require further testing to diagnose GERD. "If you've put someone on a medication once a day, and they've been on it for several weeks—upwards of 8 weeks—or you increase their dose to twice a day and they're still not getting benefit, then something to think about, to offer ambulatory pH testing to see why they're not responding to medication," said Dr. Gross.

The good news is that this testing has gotten much easier on patients. "The technology has improved, so patients don't need to walk around with a pH probe coming out of their nose," said Dr. Gross. Instead, a small wireless probe is inserted during endoscopy, and for the next 96 hours, it transmits images to a cell-phone-like box that the patient wears on his hip.

Once GERD is diagnosed, lifestyle changes should be recommended. "Just losing 5 to 10 pounds can make a tremendous difference in someone who's overweight. Raising the head of the bed—there's been some good evidence that suggests doing that," said Dr. Gross. Also, advise patients to not lie down within a couple of hours of eating heavily.

Patients don't necessarily have to avoid all their favorite foods, though. "My patients come in with laundry lists of foods they have eliminated. Oftentimes, when I ask them, 'Did the food you eliminated help your symptoms?' they say no," said Dr. Gross.

The answer to that question should be the determinant of whether a patient needs to avoid a specific food. "Sometimes patients need to keep a food diary to really figure out the foods that bother them," he said. "Not everybody has to avoid spicy foods. Not everybody has to avoid orange juice or tomato-based foods." Avoiding tobacco and alcohol has also not been proven to reduce acid reflux. "There are of course other reasons to cut those things out," noted Dr. Gross.

When patients need long-term PPI therapy, this is another time to be cost-conscious, with both dosing (daily therapy is not always necessary, if patients are symptom-free on less frequent doses) and drug choice.

"I'm sure you've all heard your patients complain about the cost of these medications. It's staggering how it can go from $17 all the way up to $240 [per month]. More expensive doesn't mean better. You could get away with some basic omeprazole over the counter and that can actually be life-changing for the patient," said Dr. Gross.



Breaking news


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ACP unveils tools for rheumatoid arthritis, chronic pain, irritable bowel syndrome, exocrine pancreatic insufficiency

ACP is releasing a series of educational materials to help patients and physicians manage rheumatoid arthritis, chronic pain, irritable bowel syndrome, and exocrine pancreatic insufficiency.

Designed with input from doctors, nurses, pharmacists, and patients, the guidebook "Live Better with Rheumatoid Arthritis" provides valuable information for patients. Patients will learn about rheumatoid arthritis (RA) medications and treatments, along with tips for healthy eating and exercise. Funded in part by the Arthritis Foundation, this guidebook also gives advice on coping with feelings and how to make everyday activities easier.

The guidebook "Relief in Sight: Coping with Long-Lasting Pain" and its accompanying DVD are designed to help patients learn about options for pain management and, along with their doctor, find treatments that work. Patients will learn that sometimes it can take time to find the right combination of treatments to relieve pain, but working closely with a health care team is a patient's best chance for effective pain management.

The "Irritable Bowel Syndrome (IBS) HEALTH TiPS" are convenient 2-sided 4-inch by 6-inch sheets designed to help clinicians and patients have more effective communication.

The IBS HEALTH TiPS, funded by Forest Laboratories, identify key concepts that reinforce messages and are written to help patients understand what they need to know and do to manage their IBS.

The guidebook "Exocrine Pancreatic Insufficiency: A Guide for Patients" and its accompanying DVD are designed to help patients learn more about signs and symptoms, diagnosis, and management of for exocrine pancreatic insufficiency (EPI). Today, people with EPI can manage the condition, which can reduce their symptoms.

These patient education materials will be available on April 10 and can be ordered online or by calling ACP Customer Service at 800-523-1546, extension 2600. "Relief in Sight: Coping with Long-Lasting Pain," "Exocrine Pancreatic Insufficiency: A Guide for Patients," and "Irritable Bowel Syndrome HEALTH TiPS" are available at no charge for all physicians and patients. ACP members can order up to 2 boxes (40 in each box) of the "Live Better with Rheumatoid Arthritis" guidebooks at no charge. Additional quantities are available for $64 per box.



For attendees


.
Physician/journalist to deliver keynote address

Elisabeth L. Rosenthal, MD, a New York Times senior writer, will deliver the keynote address at the Opening Ceremony of Internal Medicine 2014. She will speak about "Price: A Side Effect Doctors Can't Ignore" in Hall D2 from 9:30 to 10:30 a.m.

Dr. Rosenthal is working on a year-long series on health care costs and pricing. During 20 years as a reporter/correspondent for the New York Times, she has covered a wide variety of beats, from health care to international environment to general assignment reporting for 6 years in China. She is a frequent contributor to the New York Times' Sunday Review section.

Dr. Rosenthal's many journalism awards include the Asia Society's Osborn Elliott prize, the Association of Health Care Journalists' beat reporting prize, and multiple citations from the Newswomen's Club of New York. She has been a Poynter Fellow at Yale, a Ferris Visiting Professor at Princeton and an adjunct professor at Columbia University.

Born in New York City, Dr. Rosenthal received a BS degree in biology from Stanford University and an MA degree in English literature from Cambridge University, where she was a Marshall Scholar. She holds an MD degree from Harvard Medical School. She trained at New York Hospital in internal medicine and worked there in the emergency department before becoming a full-time journalist.


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On Being a Doctor book signing takes place today

The editors of On Being a Doctor, volume 4, Michael A. LaCombe, MD, MACP, and Christine Laine, MD, FACP, will be at the Annals of Internal Medicine booth in the ACP Resource Center today from 10:30 a.m. to 12:00 p.m. to sign copies of their new book.

On Being a Doctor is the latest collection of prose and poetry by physicians and patients relating individual experiences in medicine. Published by ACP, the softcover book is compiled from pieces originally published in the "On Being a Doctor," "On Being a Patient," and "Ad Libitum" sections of Annals of Internal Medicine, ACP's peer-reviewed medical journal, between 2007 and 2013.

The fourth edition of On Being a Doctor is a collection of more than 100 stories, essays, and poems in 9 sections ranging from "Those Who Are Our Patients" and "Balancing the Personal and the Professional" to "The Doctor Becomes a Patient" and "Death and Dying."

On Being a Doctor, volume 4, will be available for purchase at the ACP Store in the ACP Resource Center at Internal Medicine 2014. Or, order online or call ACP Customer Service at 800-523-1546, extension 2600 (M-F, 9:00 a.m.-5:00 p.m. ET). The list price is $31. ACP members pay $24.95.


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Meet the Consult Guys

Stop by the Annals of Internal Medicine booth today to meet The Consult Guys!

Geno J. Merli, MD, FACP, and Howard H. Weitz, MD, FACP, will be available to answer questions or discuss future episode ideas at the Annals booth in the ACP Resource Center in the Exhibit Hall today from 1:00 to 2:00 p.m. More information on The Consult Guys is online.


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It's not too late to submit a profile to the ACP Job Placement Center

Looking for a job? ACP's Job Placement Center offers career opportunities during Internal Medicine 2014. Submit a Job Seeker's Profile (mini-CV) to be included in 1 of 2 booklets based on your criteria. Your profile is guaranteed to be distributed to participating employers who submit a job posting to the center. You do not have to attend the meeting to submit a profile.

All physicians who submit a Job Seeker's Profile (limit, 1 mini-CV per physician) will be eligible for a drawing for a $100 Amazon gift card on April 12. Winners will be contacted by e-mail.

The Job Placement Center, located in the Exhibit Hall, Booth 1075, provides physicians with tools to assist in job searches, as well as the opportunity to meet with potential employers.

Submit your profile online today.





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