Transcript Hot Topics in Internal Medicine 2015 Central America Chapter XXXVII Annual Chapter Meeting IX Internal Medicine Society Congress Wayne J.

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 University
Nashville, Tennessee USA
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Disclosures
Vertex Pharmaceuticals
- Directors Fee
- Stock options
HCA Holdings, Inc.
- Director Fees
- Stock Awards
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Goals
Purpose is to review common three topics of concern among internists in
the USA.
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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
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Agenda
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2.
3.
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5.
Introduction
Ebola
Anticoagulation
Screening
Summary
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Ebola 2014
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Ebola 2014
- Outbreak began in West African country of Guinea in February
2014
- Spread to Liberia, Sierra Leone, Nigeria, Senegal, Spain and U.S.A.
- First recorded outbreak occurred in Democratic Republic of the
Congo in 1976
- Periodic outbreaks (none 1996-2000)
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Ebola 2014
- 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
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Ebola 2014
- 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
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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
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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!
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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
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Ebola
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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
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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
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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
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Anticoagulation 2015
From Bing Free Clip Arts
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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
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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
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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
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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%
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Anticoagulation 2015
 Risk Prediction/Stratification Models
• CHAD
• CHA2DS VASc
• HAS-BLED
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CHADS
 Most widely applied, simple to use
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•
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CHF
HTN
AGE > 75
DIABETES
STROKE/THROMBOEMBOLISM
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CHADS2
 MAXIMUM SCORE = 9
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•
CHF
HTN
AGE
DIABETES
STROKE
VASCULAR DISEASE
SEX
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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)
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Tanaka-Esposito & Chung. Selecting antithrombotic therapy
for patients with atrial fibrillation. CLEVELAND CLINIC JOURNAL
OF MEDICINE VOLUME 82 • NUMBER 1 JANUARY 2015
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Tanaka-Esposito & Chung. Selecting antithrombotic therapy
for patients with atrial fibrillation. CLEVELAND CLINIC JOURNAL
OF MEDICINE VOLUME 82 • NUMBER 1 JANUARY 2015
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Screening 2015
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Screening 2015: Lung Cancer
 Harm vs. Benefit —> shared decision making
 Low dose Lung CT
• 55-80 years of age
• 30-pack years
• currently smoking
• quit smoking 15 yrs.
 National Lung Screening Trial => 20% reduction in Lung CA death
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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
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Screening 2015: Vitamin D Deficiency
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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 40-54 if average risk, screen q.
2 years
 ACP: limited benefit 50-69 of average risk, No
screening < 50 or >69 with Life expectancy >10
years
 SHARED DECISION MAKING!!!
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Screening 2015: Prostate Cancer
 Remains highly controversial
 “Dueling guidelines” on the use of PSA testing
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USPSTF
ACS (American Cancer Society)
ACP
AUA (American Urological Association)
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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
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Thank You
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