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

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 z7.10 GERD z7.11 Ulcerative Colitis z5.5 Male hypogonadism

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 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

12. 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

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

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

15. Medications- Prolonged QT zhttps://www.crediblemeds.org/https://www.crediblemeds.org/ zAnti-arrhythmics zAnti-microbials- macrolides, fluoroquinolones, cholorquine, methadone zAnti-psychotics zAnti-depressants- SSRI,

16. 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%

17. QT Interval

18. zBazette’s formula zQTc = QT (sec)/ square root of RR (sec) zEx- QTc =.400 sec/ square root of 1.0 sec =.400 sec z http://www.medcalc.com/qtc.html http://www.medcalc.com/qtc.html zhttp://www.mdcalc.com/corrected-qt-interval- qtc/http://www.mdcalc.com/corrected-qt-interval- qtc/ zhttp://en.ecgpedia.org/wiki/QTc_Calculatorhttp://en.ecgpedia.org/wiki/QTc_Calculator Corrected QT (QTc)

19. 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

20. 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

21. 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

22. 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.

23. 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

24. Questions