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American College of Physicians, April 7-9, 2011

The American College of Physicians Internal Medicine 2011

The American College of Physicians Internal Medicine 2011 was held from April 7 to 9 in San Diego and attracted more than 7,000 participants from around the world, including internists, adult medicine specialists, sub-specialists, medical students, and allied health professionals. The conference highlighted recent advances in the prevention, detection, and treatment of illnesses in adults, with over 250 scientific sessions covering a variety of topics, including updates in neurology, oncology, infectious diseases, endocrinology, and cardiology.

During one presentation, Martin A. Samuels, M.D., of Brigham and Women's Hospital and Harvard Medical School in Boston, provided an update in neurology focusing on stroke, Bell's palsy, on- versus off-pump cardiac surgery, the possible causes of Alzheimer's disease, multiple sclerosis treatment, and a theory on the cause of Parkinson's disease.

"In regards to stroke, a new drug that directly inhibits thrombin may be easier for physicians and patients to use, as the drug does not require repeat blood testing like warfarin. While there may be some advantages to this drug, prior drugs in this category have been associated with some toxicities, and physicians should be [cautious] about using this drug just quite yet in clinical practice," Samuels said. "In terms of Alzheimer's disease, there is a lot of momentum regarding amyloid hypothesis. There were, unfortunately, several negative studies aimed at reducing amyloid in the brain. The question that has been arising is if amyloid is really the cause of Alzheimer's disease or is it more related to the sum of various loss of function alterations characteristic of natural aging."

Samuels also discussed two new oral drugs approved for the treatment of multiple sclerosis as well as how identification of early symptoms tied to Parkinson's disease may help to sooner identify those at risk.

"The advantages of these drugs are that they are both oral. Fingolimod works by incarcerating lymphocytes in the lymph nodes. However, prior drugs in the category have been associated with serious side effects. Another drug, cladribine, a chemotherapy drug, has shown effectiveness in multiple sclerosis but might reactivate viruses or other infections," Samuels said.

In addition, he described how new evidence has shown that some early symptoms may help to identify those at risk for Parkinson's disease.

"There are a number of symptoms -- non-motor -- that have been shown to occur in patients who later develop Parkinson's disease, including constipation, seborrhea, dizziness on standing, and REM behavior disorder," Samuels explained. "These symptoms may occur many years or even decades before the onset of Parkinson's disease. If we could suspect these symptoms earlier, we may be able to initiate treatment earlier and help individuals sooner."

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Another presentation, by Marc B. Garnick M.D., of Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, focused on the internist's role in prostate cancer diagnosis, prevention, and management. The presentation outlined the role of prostate-specific antigen (PSA) testing as well as the role of the internist in counseling patients about prostate cancer, the role of active surveillance, and the short- and long-term complications of prostate cancer therapy.

"The key points coming out of my presentation were associated with the complexities tied to the outcomes of PSA testing. The questions arise [as to] who should get tested and whether patients who are diagnosed with prostate cancer should undergo or not undergo treatment," Garnick said. "PSA screening requires a conscious discussion between patients and physicians. It is essential that this informed conversation takes place, as the discussion on PSA testing should be a shared discussion between patient and physician."

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Elizabeth Loder, M.D., M.P.H., of Brigham and Women's Hospital in Boston, discussed headache evaluation and treatment. The presentation addressed the evaluation of patients presenting with classic symptoms of migraine, best initial treatment strategy for acute management of migraine, whether prophylactic therapy should be initiated for migraine, and best options for the management of chronic daily headache.

"The clinical goal in patients with headache is to determine whether the headaches are due to some underlying problem -- in which case treatment is directed at that disorder -- or whether they are due to one of the primary headache disorders, where headache is the problem and is not due to some other disease. The 'big three' primary headache disorders are tension-type, cluster headache, and migraine. Migraine is the headache disorder most frequently encountered in medical settings. Migraine is surprisingly common," Loder said.

She added that patients who experience one or more headaches a week may benefit from preventive treatment (medicine taken every day) to decrease headache frequency.

"For migraine, U.S. Food and Drug Administration-approved migraine preventive medications include topiramate, divalproex, and propranolol. People with chronic migraine have headache 15 or more days a month; a new development here is that onabotulinum toxin type A (Botox) injections into the head and neck region are now FDA approved as a preventive treatment," Loder said.

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In a presentation providing an update in cardiology, Rita F. Redberg, M.D., of the University of California in San Francisco, discussed advances in the medical and surgical management of cardiovascular disease as well as diagnostic tools and risks.

"I discussed a meta-analysis that showed no benefit on mortality of statins for primary prevention. Based on these results, scientific evidence is lacking to support our current practice of statins for primary prevention, and we would do well to focus on lifestyle measures such as healthy diet, regular physical activity, and not smoking," Redberg said.

She noted that another topic being investigated is the use of stents compared to medical therapy for treatment of coronary disease.

"Medical therapy and stents have equivalent benefit on myocardial infarction and mortality. However, it appears that patients continue to believe that stents will prevent heart attacks and help them to live longer. We need to be sure our patients understand the risks/benefits of stents prior to the procedure and be sure they are getting the right information," Redberg explained.

She stressed that it is important that patients and physicians discuss the risks and benefits of medical treatments and procedures when appropriate to ensure the benefits outweigh the potential risks.

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A few presentations focused on psychological conditions and treatment, with one presentation by Sidney Zisook, M.D., of the University of California in San Diego, discussing how anxiety and panic disorder are diagnosed and treated in the primary care setting, how decisions between switching or adding medications are made, and other treatments beyond medications available for treatment-resistant conditions.

"Depression is a horrible, painful, miserable, and sometimes fatal disorder. But there is nothing more gratifying a physician can do than helping someone get through their depression and reestablish their reasons for living, sense of self-worth, connection to family and work, and hope for the future," Zisook said. "Practicing clinicians should optimize dose and duration of initial treatment, use case managers, psychotherapists, and psychiatric consultation liberally if available, consider switching antidepressants if optimal dose and duration do not produce at least some improvement and/or side effects are difficult to tolerate, and augmenting with another agent if the initial treatment provides a pretty good relief from most depressive symptoms and/or few side effects. Practicing clinicians should always take advantage of features that enhance well-being -- like support, bright light, exercise, [and] adequate sleep; monitor for response, side effects, adherence, [and] suicidal risk; and never give up."

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In an effort to address concerns regarding the large number of immigrants who do not have access to health insurance coverage or who face other barriers to obtaining health care, the American College of Physicians recommended a national immigration policy.

"We feel it is important to address the issue of immigration policy and impact on health care, as it is a problem coming up regularly in our health care system. It is important to look at this impact with a national perspective and make suggestions to address it. We need everyone in the United States, whether citizens, documented immigrants, or undocumented immigrants, to understand the implications of our recommendations on them," said J. Fred Ralston Jr., M.D., president of the American College of Physicians.

He noted that the organization is not suggesting that taxpayers be responsible for paying for undocumented immigrants' health insurance.

"However, we feel that, if undocumented immigrants are able to pay for their own health insurance through exchanges, then they should be allowed to, as it could benefit both documented and undocumented individuals by broadening the base and lowering the cost of insurance for others in purchasing," Ralston explained. "This would make it easier to prevent serious medical conditions, as individuals with health insurance are more likely to be cared for earlier than later. Allowing these individuals to purchase insurance could protect taxpayers from having to pay for expensive treatments in the emergency room."

The American College of Physicians also recommended that undocumented immigrants should have access to basic medical services to prevent transmission of communicable diseases, and suggested that legislators not make it a law that physicians need to turn undocumented patients over to authorities because that would slow care given to them and put all individuals at risk.

"We think our policy would advance care and positively impact everyone in the United States, regardless of their status," Ralston concluded.

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