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A busy morning in practice or “Internal Medicine 2011 – A Year in Review”

A busy morning in practice or “Internal Medicine 2011 – A Year in Review”. Molly Cooke, MD FACP Professor of Medicine UCSF Director of Education, Global Health Sciences mcooke@medicine.ucsf.edu. This morning’s schedule. Roberts, Paul (65 y.o . M) Daniels, Stanette (40 y.o . F)

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A busy morning in practice or “Internal Medicine 2011 – A Year in Review”

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  1. A busy morning in practiceor “Internal Medicine 2011 – A Year in Review” Molly Cooke, MD FACP Professor of Medicine UCSF Director of Education, Global Health Sciences mcooke@medicine.ucsf.edu

  2. This morning’s schedule Roberts, Paul (65 y.o. M) Daniels, Stanette (40 y.o. F) Tomasevich, Richard 62 y.o. M) Martin, Benjamin (20 y.o. M) Stacks, John (52 y.o.M) Crawford, Brent (82 y.o. M( Moyer, Dorothy (71 y.o. F) Laret, Susan (79 y.o. F) Feldman, Alon (48 y.o.M)

  3. Paul Roberts • 65 year old man with HIV, hyperlipidemia, CKD 2 and poorly controlled HTN • HIV medications: tenofovir and emtricitabine, boosted atazanavir • Antihypertensives: HCTZ, losartan, carvedilol, amlodopine • BP 155-165/85-90

  4. RAS blockade decreases CCB-associated edema Makani et al Amer J Med 2011; 124: 128-

  5. Bedtime anti-hypertensive therapy and cardiovascular events Hermida RC J Am So Nephrol 22:2313-2321, 2011

  6. Hypertension references • Hermida RC Bedtime dosing of antihypertensive medications reduces cardiovascular risk in CKD. J Am So Nephrol 22:2313-2321, 2011. • Makani et al. Effect of renin-angiotensin system blockade on calcium channel blocker peripheral edema. Amer J Med 2011; 124: 128-135.

  7. Stanette Daniels • 40 year old woman with palpitations • 25-OH vitamin D level 21 ng/ml “insufficient” • She has a number of questions: • How did she become vitamin D insufficient? • What form of supplementation should she take? • Will vitamin D supplementation put her at risk for heart disease

  8. Changing definition of vitamin D deficiency and increasing sales of vit D Maxmen A. The vitamin D-lemma 2011; Nature 475; 23 - 25

  9. Vitamin D References • http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ Accessed May 6, 2012 • Maxmen, A. The vitamin D-lemma 2011; Nature 475; 23

  10. Richard Tomasevich • 62 year old man with controlled hypertension and hyperlipidemia on atorvastatin 10 mg • His wife is concerned that his memory is deteriorating and wonders if the statin is to blame Chol TG LDL HDL 2002 277 82 64 197 2012 188 66 61 114

  11. Diabetes and statins Preiss D et al. JAMA 2011; 305: 2556-2564

  12. Benefits of statin therapy GoldfineNew Engl J Med 2012; 366:1752- 1755.

  13. Statin therapy • Preiss D et al. Risk of incident diabetes with intensive dose compared with moderate dose statin therapy – a meta-analysis. JAMA 2011; 305: 2556-2564 • Goldfine AB Statins: Is it really time to reassess benefits and risks? New Engl J Med 2012; 366:1752- 1755.

  14. Benjamin Martin • 20 year old man with acneon benzoyl peroxide and oral tetracycline

  15. What’s new in acne? Simpson 2011 • Combined oral and topical antibiotics should not be used together for acne. • Both oral and topical antibiotics should be stopped and a switch made to alternative topicals if no improvement • There is no good eidence for the use of botanicals such as tree tea oil • Patients requiring isotretinoinshoud be screened for depression • Lower dose isotretinoin (0.25-0.4 mg/kg/d for 24 weeks) offers a good trade-off between efficacy and dose related side-effects

  16. Acne reference • Simpson et al. What’s new in acne: an analysis of systematic reviews and clinically significant trails published in 2010-2011, ClinExper Dermatology 2011; 36:840-844.

  17. A phone interruption • 41 year old woman developed rash 1 week ago • Treated at outside ED with hydroxyzine and prednisone • Returned the next day with extension of rash and fever to 39.4 deg C. • Admitted and begun on clindamycin. • Second night fever to 39.6 with sloughing of the skin. New Engl J Med 2012; 366:1825-1834

  18. Slide courtesy of Daniel Masys, MD

  19. Differential diagnosis generators Bond WF et al. J Gen Intern Med 2011; 27:213-9

  20. Differential diagnosis generators Bond WF et al. J Gen Intern Med 2011; 27:213-9

  21. A phone call interruption http://info.isabelhealthcare.com/isabel-best-practice/

  22. Differential diagnosis generators • Bond WF et al. Differential diagnosis generators: an evaluation of currently available programs. J Gen Intern Med 2011; 27:213-9

  23. John Stacks • 52 year old man with progressive vision loss attributed to PXE; current smoker with >80 pack-year history • Minimal exercise d/t low vision • PE: barrel chest and diffusely decreased BS • PF 130-150

  24. Tiotropium mist inhaler may deliver an excessive dose Singh BMJ 2011;342:d3215. Online first

  25. COPD References • Singh S et al. Mortality associated with tiotropium mist inhaler in patients with COPD: systematic review and meta-analysis of randomised controlled trials. BMJ 2011; 342:d3215 • Vogelmeier C et al. Tiotropium versus salmeterol for the prevention of exacerbations of COPD. 2011; 364: 1093-1103.

  26. Brent Crawford • 82 year old man s/p remote BII now with dumping syndrome, remote DVT/PE treated with Greenfield filter complicated by venous stasis and ulcers, and PAF • 6 months earlier patient fell (likely orthostatic mechanism), requiring suturing for scalp lac • On 12 meds including flecainide, losartan, metoprolol, rosuvastatin, sucralfate and warfarin • INR has been largely in range for years on warfarin

  27. Risk of major bleeding: Dabigatran 110 versus 150 Eickelboom Circulation 2011; 123:2363-2372

  28. Rivaroxaban versus warfarin Patel New Engl J Med 2011; 365:888-91

  29. Apixaban versus warfarin in patients with atrial fibrillation Apixaban 5 mg BID versus warfarin to achieve INR 2-3 Granger et al. (ARISTOTLE) N Engl J Med 2011; 365:981-92

  30. Anticoagulation in atrial fibrillation • Granger et al. Apixaban versus warfarin in patients with atrial fibrillation (ARISTOTLE) N Engl J Med 2011; 365:981-92

  31. Dorothy Moyer • 71 year old woman with mixed incontinence • Madhuvrata P et al. Which anticholinergin drug for overactive bladder symptoms in adults. Cochrane Review 2012 • Low dose solifenacin (5 mg) as efficious as tolteridine with fewer side-effects • Tolteridine as effective as oxybutinin with fewer sidde-effects

  32. Susan Laret • 79 year old woman with mild dementia here for pre-op eval prior to elective THA for painful DJD • Husband notes forgetfulness • MMSE 21/30 • Benefits of proposed surgery: “It will fix my hip” • Risks and alternatives: “It will be fine”

  33. Performance of Tests for Formal Assessment of Decision-making Capacity ACE Aid to Capacity Evaluation HCAT Hopkins Competency Assessment Test UTD Understanding Treatment DisclosureACQ Ability to Consent Questionnaire Sessums JAMA 2011; 306:420

  34. Aid to Capacity Evaluation - 1 Etchells J Gen Intern Med 1999 14:27-34

  35. Aid to Capacity Evaluation - 2

  36. This morning’s schedule Roberts, Paul (65 y.o. M) Daniels, Stanette (40 y.o. F) Tomasevich, Richard 62 y.o. M) Martin, Benjamin (20 y.o. M) Stacks, John (52 y.o.M) Crawford, Brent (82 y.o. M( Moyer, Dorothy (71 y.o. F) Laret, Susan (79 y.o. F) Feldman, Alon (48 y.o.M)

  37. Capacity assessment references • Sessums LL e al. Does this patient have medical decision-making capacity? JAMA 2011; 306: 420-427. • ACE tool and training material http://www.jointcentreforbioethics.ca/tools/documents/ace.pdf Accessed May 6, 2012

  38. ACP Internal Medicine • San Francisco 4/11- 13, 2013 • Orlando 4/10-12, 2014 • Boston 4/30 – 5/2, 2015 • Washington DC 5/5-7, 2016 • San Diego 3/30 – 4/2, 2017 • New Orleans 4/19-21, 2018

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