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1 Hot Topics in Internal Medicine 2015 Central America Chapter XXXVII Annual Chapter Meeting IX Internal Medicine Society Congress Wayne J. Riley, M.D.,

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Presentation on theme: "1 Hot Topics in Internal Medicine 2015 Central America Chapter XXXVII Annual Chapter Meeting IX Internal Medicine Society Congress Wayne J. Riley, M.D.,"— Presentation transcript:

1 1 Hot Topics in Internal Medicine 2015 Central America Chapter XXXVII Annual Chapter Meeting IX Internal Medicine Society Congress Wayne J. Riley, M.D., MPH, MBA, MACP President Elect American College of Physicians Clinical Professor of Medicine Vanderbilt University School of Medicine Adjunct Professor of Healthcare Management Vanderbilt Owen Graduate School of Management Vanderbilt Universit y Nashville, Tennessee USA

2 2 Disclosures Vertex Pharmaceuticals - Directors Fee - Stock options HCA Holdings, Inc. - Director Fees - Stock Awards

3 3 Goals Purpose is to review common three topics of concern among internists in the USA.

4 4 Objectives Participants will be able to: 1. List common symptoms, clinical presentation, lab data and treatment of Ebola. 2. Compare and contrast the risks and standards of care for patients requiring anticoagulation. 3. Describe screenings for vitamin D, lung cancer, and Prostate Cancer

5 5 Agenda 1. Introduction 2. Ebola 3. Anticoagulation 4. Screening 5. Summary

6 6 Ebola 2014

7 7 - Outbreak began in West African country of Guinea in February Spread to Liberia, Sierra Leone, Nigeria, Senegal, Spain and U.S.A. - First recorded outbreak occurred in Democratic Republic of the Congo in Periodic outbreaks (none )

8 8

9 9 Ebola Etiologic agent is related to the Marburg Virus (single strand RNA Virus) - Transmission via contact with blood, urine, sweat, feces - ? Airborne transmission recently reemphasized - > 23,000 cases; 9,300 deaths - 5 strains: Zaire, Bundibugyo, - Sudan, Reston, Tai

10 10 Ebola First USA case: September 30, 2104 in patient who had recently travelled from Liberia to Dallas, Texas - Developed symptoms within 4 days of arriving from West Africa - Two nurses who carried for him subsequently were diagnosed with Ebola confirming its nosocomial spread in a healthcare facility - Nursing Assistant in Spain contracted Ebola in the course of caring for two Spanish missionaries

11 11 Ebola 2015 – Clinical course - Mimics a wide variety of viral diseases and syndromes especially Influenza, malaria and typhoid fever - Symptoms are non-specific but characterized by fever, lassitude, chills, myalgia, nausea vomiting, abdominal pain - Accurate AND detailed Travel and/or Occupational history is critical

12 12 Ebola 2015 – Clinical course - Onset of symptoms is between 2-21 days post exposure contact with infected persons, but generally presents acutely 8-10 days - Hemorrhagic sequelae mucosal bleeding, petechiae, ecchymoses, hematochezia - Voluminous G.I. efflux - All body fluids are deemed to be highly infectious!

13 13 Ebola 2015 – Clinical course - Blood, sweat, feces, vomitus are HIGHLY infectious, thus the need for Personal Protective Equipment (PPE) protocols - Most virulent cases tend to present severe disease course 6-10 days after onset - Non fatal cases: slow recovery, fatigue, poor appetite, significant weight loss

14 14 Ebola

15 15 Ebola 2015 – Clinical course - LABS: Thrombocytopenia, elevated LFT's, profound neutropenia with "left shift, prolonged PT/PTT and evidence of DIC. - Diagnostic Testing: FDA yesterday approved ReEBOV Antigen Rapid Test, standard testing is by PCR, Viral Culture, and IgM and IgG ELISA - In U.S. only CDC and very few State Health Departments are equipped with biosafety infrastructure to test specimens

16 16 Ebola 2015 – Treatment  Supportive Rx – blood products, vigorous electrolyte/fluid resuscitation, vasopressor support, ventilator support  Maintain mean Arterial BP to ≥ 65 mm Hg  No licensed agents for Ebola and No licensed vaccines

17 17 Ebola 2015 – Treatment  Investigational medications include: Zmapp a combination of 3 monoclonal antibodies; Brincidofovir an antiviral for -CMV and Adenovirus  U.S.A. National Institutes of Health (NIH) reported interim data on phase I vaccine trial using a vesicular stomatitis virus which expresses Ebola surface glycoprotein

18 18 Anticoagulation 2015 From Bing Free Clip Arts

19 19 Anticoagulation 2015  Oral anticoagulation has been a remarkable success story in markedly decreasing the mortality in atrial fibrillation (AF) and embolic phenomenon  Key clinical conundrum is weighing the possible benefit of antithrombotic therapy versus the risk of bleeding in patients with atrial fibrillation

20 20 Anticoagulation 2015  Antithrombotic Therapy: antiplatelet Rx; as Aspirin and Clopidogrel and the anticoagulants such as Warfarin and the newer Target Specific Oral Anticoagulants (TSOACs)  Valvular AF has the greatest risk of systemic embolization and thus nearly ALL patients with valvular AF need anticoagulation

21 21 Anticoagulation 2015  Nonvalvular AF has a comparatively lower risk  Newer clinical guidelines minimize the use of Aspirin but it remains a viable options in selected situations  New oral anticoagulants have been introduced for patients with nonvalvular AF

22 22 Anticoagulation 2015  AF is often seen condition in practice with a patient's lifetime risk of 25% (Framingham Heart Study)  10% of those > 80 years of age  Also greater incidence of cardiovascular disease  Lifetime risk of developing AF is 25%

23 23 Anticoagulation 2015  Risk Prediction/Stratification Models CHAD CHA2DS VASc HAS-BLED

24 24 CHADS  Most widely applied, simple to use CHF HTN AGE > 75 DIABETES STROKE/THROMBOEMBOLISM

25 25 CHADS2  MAXIMUM SCORE = 9 CHF HTN AGE DIABETES STROKE VASCULAR DISEASE SEX

26 26 HAS BLED  Maximum Score 9: Should not be used to exclude, but identify high risk HTN Abnormal renal function (Cr > 2.6) or Liver function (LFT’s > 3X’s) Stroke Bleeding Labile INR Drugs (NSAIDS, alcohol, antiplatelet)

27 27 Tanaka-Esposito & Chung. Selecting antithrombotic therapy for patients with atrial fibrillation. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 82 NUMBER 1 JANUARY 2015

28 28 Tanaka-Esposito & Chung. Selecting antithrombotic therapy for patients with atrial fibrillation. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 82 NUMBER 1 JANUARY 2015

29 29 Screening 2015

30 30 Screening 2015: Lung Cancer  Harm vs. Benefit —> shared decision making  Low dose Lung CT years of age 30-pack years currently smoking quit smoking 15 yrs.  National Lung Screening Trial => 20% reduction in Lung CA death

31 31 Screening 2015: Vitamin D Deficiency  Vitamin D via food and skin synthesis (UV) B exposure  Associations between low 25-hydroxyvitamin D levels in falls, cvd, colorectal cancer, diabetes, depressed mood, cognitive decline and death  No consensus on who high vitamin D should be and levels < 50nmol/mL better for bone health

32 32 Screening 2015: Vitamin D Deficiency

33 33 Screening 2015: Prostate Cancer  USPSTF: grade D recommendation  ACS: No PSA without dialogue with patient; start PSA at 50, African American at 45  AUA: No screening if average risk, screen q. 2 years  ACP: limited benefit of average risk, No screening 69 with Life expectancy >10 years  SHARED DECISION MAKING!!!

34 34 Screening 2015: Prostate Cancer  Remains highly controversial  “Dueling guidelines” on the use of PSA testing USPSTF ACS (American Cancer Society) ACP AUA (American Urological Association)

35 35 Summary  All Internists and the medical community should be knowledgeable about Ebola  Anticoagulation remains a impressive achievement given the Rx. with Warfarin and the TSOACS after careful risk stratification  Screening for Vitamin D, Lung CA and Prostate Cancer remain confusing but necessary in some patients

36 36 Thank You


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