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Internal Medicine Update USNAC 2015 CAPT R. Wesley Farr, MC, USN Infectious Diseases Aerospace Medicine Naval Aerospace Medical Institute Robert.

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Presentation on theme: "Internal Medicine Update USNAC 2015 CAPT R. Wesley Farr, MC, USN Infectious Diseases Aerospace Medicine Naval Aerospace Medical Institute Robert."— Presentation transcript:

1 Internal Medicine Update USNAC 2015 CAPT R. Wesley Farr, MC, USN Infectious Diseases Aerospace Medicine Naval Aerospace Medical Institute Robert.

2 Disclosures zThe views expressed in this presentation are those of the author and do not reflect the official policy or position of the U.S. Department of the Navy, U.S. Department of Defense, or the U.S. government. zNo financial, professional, or personal conflict of interest

3 Objectives zApply recent revisions in ARWG to your aeromedical practice zEvaluate elevated fasting glucose for AMS submission zEvaluate thrombocytopenia for AMS submission zEvaluate Prolonged QTc Interval for AMS submission

4 Outline z5.1 Diabetes mellitus/Prediabetes zThrombocytopenia zProlonged QTc zEbola

5 Categories of Increased Risk for Diabetes zImpaired Fasting Glucose (IFG) yFPG 100-125 mg/mL (5.6-6.9 mmol/L) zImpaired Glucose Tolerance (IGT) y2-h plasma glucose in75-g OGTT 140-199 mg/dL (7.8-11.0) zPrediabetes yHgbA1c 5.7-6.4% zAmerican Diabetes Association. Diabetes Care 2011;34(Suppl 1);S11-S61.

6 Significance of Prediabetes zNot clinical entities zRisk factors for future diabetes and cardiovascular disease (CVD) zStrong continuous association between HgbA1c and future diabetes zAmerican Diabetes Association. Diabetes Care 2011;34(Suppl 1);S11-S61.

7 A1c Level and Risk of Diabetes zRisk of DM increased steeply from A1C 5.0-6.5 zA1C 6.0-6.5%- risk 20 or more times greater than A1C <5.0% zA1C 5.5-6.0%- risk 5 times greater than A1C <5.0% zA1C 5.0-5.5%- risk 2 times greater than A1C <5.0% zZhang et al. A1C level and future risk of diabetes: a systematic review. Diabetes Care 2010;33;1115-1673.

8 Zhang X et al. Dia Care 2010;33:1665-1673 Copyright © 2014 American Diabetes Association, Inc. A1C modeled as a function of annualized incidence.

9 Waiver Requirements for Prediabetes z5.1.1 Dysglycemia- new section separate from Diabetes mellitus zAviator does not need to be grounded during evaluation zFamily Medicine or Int Med consult zFundoscopic exam zNutrition consult zFBG; HgbA1c < 6.5, TSH, CMP, Lipids, UA, Urine microalbumin:urine creatinine ratio (<300)

10 Impact on Workload JUL 2013-MAR 2014APR 2014- JAN 2015 NAMI IM Consults04 NAMI IM Clinical Advisories 116

11 Thrombocytopenia JUL 2013-JAN 2015 NAMI IM Consults17 NAMI IM Clinical Advisories 14

12 Case Study- Thrombocytopenia zProb- Asked by Dr. McKee to see 21-y-o AD USN male NAC rescue swimmer applicant with thrombocytopenia. zHPI- Asymptomatic with thrombocytopenia (99K, 111K). zHigh school- football, wrestling zPFA- Sit-ups- 80; Push-ups- 80; 1.5 mile Run- 9:00 zSurgery- Left ACL reconstruction 2008 zROS- neg zPE- WNL

13 Labs 1 AUG 143 DEC 149 DEC 1410 DEC 14 Platelets128K111K99K108K Hgb15.815.1 15.0 Hct44.844.644.942.7 WBC7,7003,7003,4003,900 CMP WNL UAWNL LDH (98- 192) 139

14 Labs 1 AUG 143 DEC 149 DEC 1410 DEC 14 B12 (180- 914) 611 Folate (5.9-24.8) 12 Iron (45- 182) 128 Ferritin (23.9- 336.2) 44.3 Ferritin (23.9- 336.2) 44.3

15 Labs 1 AUG 143 DEC 149 DEC 1410 DEC 14 Anti-HIVneg HBs Agneg Anti-HCVneg H pylori Ab <0.9- neg Chest PA/LAT WNL US Liver Spleen WNL

16 Case Study zImpression- Thrombocytopenia- CD zAeromedical Disposition- NPQ- waiver recommended. zRecommendations- yNo restrictions on flight activities yAnnual waiver submissions with CBC and platelet count >100K

17 Thrombocytopenia zARWG pending zPlatelet count less than 150K- CD zWaiver recommended- yStable platelet count 100-150K yNegative lab and imaging work-up zHematology consult- yPlatelet count less than 100K yBone marrow

18 Thrombocytopenia Eval zCBC, UA, CMP, LDH zB12, Folate, Iron, Ferritin zTSH zHIV Ab, HBsAg, HCV Ab; H pylori Ab zCXR PA/Lat zUS spleen/liver

19 Prolonged QTc zARWG pending zQT interval- measurement yVaries with heart rate yShortens with fast HR yLengthens with slow HR zQTc- Corrected QT interval

20 Aeromedical Concerns of Prolonged QTc zSyncope, ventricular tachycardia, sudden cardiac death zMedications zHypocalcemia zHypothyroidism zCongenital Long QT Syndrome (LQTS)

21 Medications- Prolonged QT z zAnti-arrhythmics zAnti-microbials- macrolides, fluoroquinolones, cholorquine, methadone zAnti-psychotics zAnti-depressants- SSRI,

22 Congenital LQTS zSyncope and cardiac arrest in childhood and teenagers zRapid, polymorphic v tach zOver 300 mutations in 7 genes accounting for 70% of patients with LQTS zGenetic testing y5 cardiac ion channel genes ySensitivity 70%

23 QT Interval

24 zBazette’s formula zQTc = QT (sec)/ square root of RR (sec) zEx- QTc =.400 sec/ square root of 1.0 sec =.400 sec z z qtc/ qtc/ z Corrected QT (QTc)

25 zECG computer yOften artificially prolonged QT- tail of T wave zManual measurement of QT yDraw slope of T wave on paper yMark where T slope crosses isolectric point yManually measure QT interval and insert in calculator Measurement of QT/QTc

26 Computer QT/QTc

27 Preferred Straight Edge

28 T Wave Downslope

29 Manual QT/QTc

30 Alternative Straight Edge

31 Disclosures zNo financial interest in Skilcraft or The Tool Shack

32 Proposed Prolonged QT Interval Policy zManual QTc <440 msec males (<460 females)- NCD zManual QTc 440-459 msec males (460-479 msec females)- CD, Waiver considered. Worksheet. zManual QTc 460-499 msec males (480-499 msec females)- CD, Waiver considered. Worksheet, EST, Cardiology zManual QTc >500 msec males (>500 msec females)- CD, Waiver not considered

33 Prolonged QT Interval Worksheet zPersonal History (present or past history) yYes___No___Palpitations yYes___No___Presyncope yYes___No___Syncope (with stress) yYes___No___Syncope (without stress) yYes___No___Cardiac Arrest yYes___No___Long QT Syndrome

34 Prolonged QT Interval Worksheet zYes___No___Medications (prescription/OTC/supplements) (list) x____________ zFamily History yYes___No___Unexplained sudden cardiac death (any first degree relative prior to the age of 30 without antecedent trauma or prolonged illness) yYes___No___Long QT Syndrome zObtain EST and Cardiology Consult if Personal History or Family History is positive.

35 Prolonged QT Interval Worksheet zLab- K +, Ca 2+, TSH zSupine and Standing (30 seconds after standing from supine) 12 Lead Electrocardiograms DateType ECGHR QT (msec) (computer) QTc (computer) Manual QTManual RRManual QTc Initial Screening Supine Standing

36 Ebola

37 Disclosures zI do have financial interest in Coca Cola. z10 shares in USAA brokerage account

38 Table: Chronology of previous Ebola virus disease outbreaks 1972-2012 z2387 cases in 28 outbreaks yRange 1-425; Mean 85.3 z1590 fatalities (66.6% fatality rate) yRange 0-280; Mean 56.8 zSingle country outbreaks z

39 WHO Outbreaks

40 Countries with Widespread Transmission zCDC. January 9, 2015. counts.html CountryTotal Cases Laboratory- Confirmed Cases Total Deaths Guinea279324931797 Liberia862331233515 Sierra Leone1003077592977 Total21086133768289

41 Ebola 2014- West Africa

42 Numbers of Confirmed and Probable Ebola Cases Reported Weekly from Guinea, Sierra Leone, and Liberia from December 23, 2013, to August 11, 2014. Briand S et al. N Engl J Med 2014;371:1180-1183.

43 Chain of Infection- Ebola zAgent- Ebola virus zReservoir- Fruit bats of the Pteropodidae family z zSecondary- chimpanzees, gorillas, monkeys, forest antelope and porcupines

44 Chain of Infection- Ebola zTransmission yClose contact with the blood, secretions, organs or other bodily fluids of infected animals yHuman to human transmission zHost- Humans zSyndrome- Viral hemorrhagic fever

45 Human-to-Human Transmission zDirect contact through broken skin or mucous membranes zBlood, secretions, organs, body fluids zSurfaces and materials- bedding, clothing zBurial ceremonies- direct contact with body zTransmission through semen for up to 7 weeks z

46 HCW

47 Ebola in the DoD zChairman of the Joint Chiefs of Staff Instruction 4220.01: Post-deployment policy for 21-day controlled monitoring of DoD Service members, civilians, and contractors returning from Ebola Virus Disease outbreak areas in West Africa and CONUS zMHS References and Training Files y yPPE list for HCW yDD Form 2991- EVD Re-deployment Risk Assessment yDD Form 2990- EVD Exposure Risk Evaluation zDoD personnel in Liberia- logisitics; HCW trainers zUSNORTHCOM- deploy within the United States in support of Civil Authorities.

48 Tiered Hospital Plan

49 Burial Training 1 z

50 Burial Training 2- Swab

51 Burial Training 3- Body retrieval

52 Burial Training 4- Sample handling

53 Burial Training 5- Sample transport

54 Burial Training 6- Body transport

55 Burial Training 7- Decon

56 Questions

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