Internal Medicine 2015 HighlightsRyan D. Mire, MD, FACP

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Assessing and Managing Testosterone Abnormalities in All Your Patients (MTP 022) - Dr. Matsumoto

Most reliable testosterone level is early morning (~ 8 am) and fasting.• Should be repeated x 1 to confirm low level

Biologic variability ~30% fluctuation day to day

Requires BOTH symptoms and low level to meet diagnosisModerate obesity decreases SHBG• Check SHBG and free testosterone levels in obese • Other factors: steroids, hypothyroidism, and nephrotic syndromeFemales: with PCOS and hirsuitism, testosterone levels are not required.

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Evaluation and Management of Kidney Stones (MTP 077) – Dr. Curhan

20% men / 9% women will have a kidney stone in lifetime.Accounts for $2 billion / year in US healthcare expenditures

Wait 6 weeks prior to 24 hour urine for metabolic work-upDietary calcium associated with decreased risk of stones, but calcium supplements can increase risk.

Calcium oxalate stones (70%) - do not advise a low calcium diet!

First time stone does not require metabolic workupRenal U/S is adequate for follow-up/surveillance of stones

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Lung Cancer Screening (PN 035) – Drs. Kane, Nana-Sinkam, and Redberg

Using LDCT for screening, ~ 25% will have nodules and ~ 10% of nodules will be cancerousLDCT is ~ ¼ of the radiation exposure of standard CT

The most impactful intervention in the past 10 year to affect a disease of high mortality

Despite patient inclusion guidelines by USPSTF, risk stratification is essential for best screening outcome.• PLCOm2012 model (risk calculator) > USPSTF

factors: ethnicity, SES, BMI, Ca hx, COPD, FHx of cancer• http://www.brocku.ca/lung-cancer-risk-calculator

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Lung Cancer Screening (PN 035) – Drs. Kane, Nana-Sinkam, and Redberg

Smoking cessation is much less expensive than LDCT annual screening!!!• Remains the #1 impact on lung cancer incidence

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Clinical Triad: The Experts Weigh in on Obesity (CT 001) – Drs. Cody-Stanford, Schirmer, and Puri

Laparoscopic sleeve gastrectomy is now the most common U.S. surgery (~45% of all surgeries)Mortality is 30% greater for every 5 point in BMI above 25 (independent of age)Indications for bariatric surgery:

Failed lifestyle efforts (minimum of 6 months)BMI > 35 with co-morbidities or BMI > 40 Psychiatrically stable

Monitor for nutritional deficiencies:- iron, vitamin B12, folate, and vitamin D

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Clinical Triad: Immunizations in Adults, Travelers, and Healthcare Workers (CT 003) – Drs. Schaffner, Freedman, and Talbot

Lifetime risk of shingles is ~ 33% and with age No need to have a hx of chicken pox or to do a

varicella titer – just give the vaccineShingles vaccine is license for 50 y.o. and older, but proven benefit only last ~ 10 years and only a 1 time vaccine, so optimal to wait until age 60New recommendation for pneumococcal conjugate vaccine (PCV13) in patients > 65 (as of August 2014)

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Clinical Triad: Immunizations in Adults, Travelers, and Healthcare Workers (CT 003) – Drs. Schaffner, Freedman, and Talbot

• No pneumococcal vaccine:- PCV13 first, followed by PPSV23 one year

later*Can be practically be given 8 weeks

later, but CMS will only reimburse if given one year apart

• If PPSV23 has been given:- Wait at least one year before PCV13 is

given.

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Clinical Triad: Hypertension – Devices, Drugs, and Diet (CT 004) – Drs. Cohen, Nesbitt, and Taler

White coat hypertension occurs in ~ 20% with untreated hypertensionAt night, BP should drop ~ 15%. However, higher rate of CV events when nighttime BP is elevated.

- compared to self monitoring, ambulatory BP monitoring provides data during sleep hours

For persistent proteinuria, add aldosterone antagonistEvidence does not support renin-angiotensin-aldosterone system (RAAS) blockade

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Providing High Value in Cardiology Care (MTP 004) – Dr. Merz

In 2012, the NHLBI removed themselves from the guideline business. In August of 2013, the ACC/AHA took overNew and lower threshold for the ASCVD 10 year risk calculation cutoff from 10% down to 7.5%!No longer treat to targeted LDL levels

- use moderate (30-50%) / high (> 50%) intensity statins

African American ethnicity factors in risk calculationRoutine LFT checks no longer recommended

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Lipid Management 2015: What Works, What Doesn’t (MTP 009) – Dr. Duffy

Algorithm for risk score calculator is very driven by age controversy for overestimation in healthy pts ASCVD patients (secondary prevention)

< 75 years old – use high intensity statin Atorvastatin 40-80mg dose / Rosuvastatin 20 - 40mg dose

> 75 years old – use moderate intensity statinRisk calculator is class IIb recommendation for other ethnic populations (e.g. Hispanics, American-Indians)Clinical judgment must always prevail the decision to initiate any treatment

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Clinical Triad: Anticoagulants Update (CT 002) – Drs. Deo, Ma, and Zumberg

For ~ 50 years, we only had one option for oral anticoagulation…now four options in the past 5 yearsNone approved for patients with mechanical valve replacementAtrial fibrillation – new scoring system CHA2DS2VASc

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Clinical Triad: Anticoagulants Update (CT 002) – Drs. Deo, Ma, and Zumberg

Comparison of Warfarin to newer agents

Anti Xa assay or thrombin time levels are only useful for qualitative, not quantitative.

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Headache Evaluation and Management (MTP 079) – Dr. Loder

Aura occurs in ~ 30% of migrainesFocal neurologic symptom: visual, sensory, or

motorAvoid recommendation for prolonged or frequent use of OTC analgesics even for mild headachesTriptan non-responders…suboptimal management???

dose too low?

did not treat early enough?suboptimal formulation?

Avoid neuroimaging in stable pattern headaches that meet criteria for migraines

- Head MRI is the imaging of choice (exceptions: ER, SAH)

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Thyroid Management (PN 013) – Drs. Wartofsky, Cooper, and Gharib

95% of thyroid nodules are benignWhen should be biopsy?

Nodules 1 cm with high suspicion sonographic pattern

Nodules 1 cm with intermediate suspicion US pattern

Nodules 1.5 cm with low suspicion US pattern

Nodules 2 cm with very low suspicion US pattern

20% of thyroid FNA pathology are indeterminate•25% of those are malignant after surgical diagnostic thyroid lobectomy•Molecular genetics to decrease number of unnecessary surgeries

Cytologically benign nodules can be followed at 1 year and then at 5 years