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Hot Topics in Internal Medicine 2015Central America Chapter

XXXVII Annual Chapter MeetingIX Internal Medicine Society Congress

Wayne J. Riley, M.D., MPH, MBA, MACPPresident Elect

American College of PhysiciansClinical Professor of Medicine

Vanderbilt University School of MedicineAdjunct Professor of Healthcare Management

Vanderbilt Owen Graduate School of ManagementVanderbilt 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

1. Introduction2. Ebola3. Anticoagulation4. Screening5. 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

• CHF• HTN• AGE > 75• DIABETES• STROKE/THROMBOEMBOLISM

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CHADS2

MAXIMUM SCORE = 9• 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)

27Tanaka-Esposito & Chung. Selecting antithrombotic therapyfor patients with atrial fibrillation. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 82 • NUMBER 1 JANUARY 2015

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Tanaka-Esposito & Chung. Selecting antithrombotic therapyfor 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

• 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