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March 2011


    ACP Clinical Guidelines

    ACP Clinical Guidelines

    ACP Clinical Practice Guidelines cover many areas of internal medicine, including screening for cancer or other major diseases, diagnosis, treatment and medical technology. Click here for more

    Use of Intensive Insulin Therapy for the Management of Glycemic Control in Hospitalized Patients

    February 14, 2011 | Volume 154 Issue 4

    Recommendation 1: ACP recommends not using intensive insulin therapy to strictly control blood glucose in non–surgical intensive care unit (SICU)/medical intensive care unit (MICU) patients with or without diabetes mellitus (Grade: strong recommendation, moderate-quality evidence).

    Recommendation 2: ACP recommends not using intensive insulin therapy to normalize blood glucose in SICU/MICU patients with or without diabetes mellitus (Grade: strong recommendation, high-quality evidence).

    Recommendation 3: ACP recommends a target blood glucose level of 7.8 to 11.1 mmol/L (140 to 200 mg/dL) if insulin therapy is used in SICU/MICU patients (Grade: weak recommendation, moderate-quality evidence).

    To read the complete Guideline, click here.



    Update Your Knowledge with MKSAP 15 Q & A

    A 29-year-old woman is evaluated for bilateral breast pain, which she has experienced off and on for 6 months. The pain is diffuse, aching, radiates to her upper arms and axillae, and typically occurs or worsens towards the end of her menstrual cycle. She denies any localized pain, mass, or nipple discharge. Medical and family history are unremarkable. She takes no medications and has no allergies. The patient has never had a mammogram.

    On physical examination, vital signs are normal. BMI is 30. Her breasts have mild tenderness bilaterally. There is no mass or nodularity, no skin changes or nipple discharge, and no lymphadenopathy.

    After reassuring the patient that her pain is unlikely to be due to breast cancer, which of the following is the next management option?

    A. Bilateral mammography
    B. Breast ultrasound
    C. Danazol
    D. Tamoxifen
    E. Well-fitting support bra

    Click here for the answer and critique.



    Internal Medicine: Global Perspectives

    Werner Bauer, MD, FACP

    The European Federation of Internal Medicine (EFIM) is a scientific organization founded in 1996 by the Association Européenne de Médicine Interne (AEMI)*. AEMI was founded in 1969 by members of the Union of European Medicine Specialists (UEMS monospecialty section on internal medicine to provide a scientific organization of internal medicine on a European basis. EFIM was formed by bringing together the national societies of internal medicine in each of the European countries, both inside and outside the European Union. EFIM currently comprises 33 member Societies representing over 30,000 internists. The purpose of EFIM is to re-emphasize the importance of internal medicine in patient care in a world of increasing specialization.

    * Source: www.efim.org

    What inspired you to become a physician?

    The pediatrician who cared for me when I was a boy was my role model and he inspired me to pursue a career in medicine. I was always fascinated by Medicine as a discipline growing up and I wanted to pursue a profession which allowed me to build relationships and work with people.

    What is the role of “internist” in Switzerland? What do people expect and want from their internists?

    The population of primary care doctors in Switzerland consists of two-thirds general practitioners and one-third general internists who practice in private practices. In Switzerland, internists work in hospitals on the general internal medicine wards as well as in outpatient medicine. After completing the required postgraduate training, internists are board certified in general internal medicine or may be certified in a subspecialty or in both fields. Currently, there is an enormous lack of young general practitioners but there is a slightly less dramatic lack of young internists. People expect their internist to have expertise in general medicine, in decision making, in disease management and in multimorbidity. They also like to have easy access to the doctor and a long-term relationship.

    Are there special challenges internists in Switzerland face? What are your thoughts on the best way to meet those challenges?

    One of the challenges that internists face in Switzerland is the fact that our country does not have enough doctors in training and not enough doctors for all hospital positions and for primary care. Switzerland needs immigration from Germany and from other countries to be able to fill all hospital positions. Many young doctors in Switzerland choose other medical specialties over internal medicine because of the higher income, the prestige, the smaller range of responsibilities, and the more attractive work hours associated with certain specialties. As the majority of the medical students now are women, it is crucial to adapt the work conditions to their way of life. Young internists are pursing career paths in private practice but instead are looking for a good job in a hospital or in a medical center.

    As of January 1, 2011, the specialty “General Medicine” (GP`s) has been abolished in Switzerland. All doctors planning a career as an internist in the hospitals, as well as physicians practicing in outpatient internal medicine, or primary care will now have to obtain the same board certification as general internists.

    What are the most common chronic illnesses in Switzerland or in your country and how do they affect the day-to-day job of an internist?

    As in our neighboring countries and in the United States, cardiovascular diseases, psychosomatic problems, multimorbidity including diabetes and hyperlipidemia, as well as cancer, and rheumatologic problems are all prevalent illnesses in Switzerland. Along with the care of trained specialists, patients with these illnesses need a good continuous relationship with a personal doctor, a generalist, and an internist who acts as the disease manager. This procedure of coordinated care avoids costly and painful unnecessary or doubled procedures and ensures proper diagnostic treatment and care.

    Are there enough young physicians In Switzerland choosing to be internists? What makes them do so? What are the barriers to entry?

    There is a lack of doctors in all disciplines in Switzerland. The main reason for this is the lack of enough space at the Swiss medical schools to accept all of the students. Due to the lack of space, we are only able to train two thirds of the students that would like to become physicians. The lack of funding for medical schools contributes to this problem. Some attractive technical disciplines face fewer problems finding candidates but fortunately there are still many young doctors choosing internal medicine with or without a subspecialty.

    Is there public debate about Switzerland’s health care system?

    There is an ongoing debate about financing the very good health care system that Switzerland has. Every inhabitant of Switzerland has mandatory health insurance. People who are unable to pay the entire insurance fee get support by the state. Nearly all procedures and medications are covered by the insurance companies. Hospitals receive 50 percent funding from the public. There is a discussion about how to limit the steady increase of the insurance premiums and also discussions surrounding the limitation of some expensive diagnostic procedures and treatment methods. One example is the new, expensive cancer medication. Are there limits on costs per year which should be covered by the insurance? There is also a debate about reducing the number of hospitals since the average person in Switzerland lives only around 15 kilometers from a hospital.

    Do you admire the health care systems of other countries and if so which ones and why?

    To admire is too strong of a word. Our health care experts travel everywhere and find good elements in health care systems of many countries, especially in the Netherlands, in the Scandinavian countries, in Canada, in the US (science and management, not so much in the insurance models). There is one difficulty: even though Switzerland is a small country, there are still 26 different states (referred to as canton) and each state is independent in organizing its own health care.

    What could other countries learn from your health system?

    All inhabitants are covered without discrimination. From inexpensive medication to heart transplants, no treatment is dependent on a person’s social status. Switzerland also has five very good medical schools and very good training programs for young doctors preparing to take board examinations. We get many foreign medical graduates who apply for their specialty training in Switzerland. We also have good community health care in Switzerland, community nurses and primary care doctors work very well together.

    Is access to electronic information or products influencing what patients want from their doctors in Switzerland?

    This is absolutely true for Switzerland’s middle aged population and the younger generation. People get both good and bad unselected information from the internet. It may be good in one way that the information is available on the internet, but it also produces anxiety in patients, wrong ideas, and wrong expectations.

    What did you find to be the most challenging part of your previous role as the President of the EFIM ? What have you found to be the most rewarding?

    To be an EC member and the president of the EFIM is fascinating, a demanding time commitment but is also a very rewarding job. It is a challenge to chair the meetings of the delegates of 35 countries with very different systems and to set up projects which meet the approval of all of them. It is a challenge to advocate for the position of internal medicine, the discipline we all love, in the European health care systems. This work is so important because we feel that internal medicine has an important role in the ages of multimorbidity, demographic changes and lack of resources. I had to face a special challenge when the annual congress in 2010 was cancelled by the organizing country and when my colleagues and I had to set up a “salvage scientific event” in a very short amount of time. The most rewarding part of the presidency is the friendship I found in the EFIM and the feeling and the hope that I have been able to contribute a little to the aims and goals of the Federation.

    What are your leadership responsibilities as Immediate Past President of the European Foundation of Internal Medicine (EFIM)?

    The immediate past president participates in the work of the Executive Committee of the EFIM and of the Council of the EFIM Foundation. I have some specific projects where I am responsible or especially active (EFIM Fellowship, political issues of internal medicine). Of course the past president can share many experiences with his colleagues but he should no longer try to push his own ideas too much.

    Does the EFIM have collaborative relationships with other societies and if so, is this beneficial to the EFIM and how?

    Of course the EFIM has intensive relationships with all 35 member societies. The EFIM has a very important and inspiring relationship with ACP, which we value as very good collaboration and friendship. In addition we have contacts with the International Society of Internal Medicine and with societies of internal medicine all over the world. These inputs are important and helpful.



    International Meetings Update

    The Annual Meeting of the Association of Physicians of India
    January 6-9, 2011

    The Annual Meeting of the Association of Physicians of India (APICON) was held January 6-9, 2011 in Ahmedabad, India. Over 5,000 physicians from all over India and abroad participated in the conference.

    J. Fred Ralston, Jr., MD, FACP, President, ACP, and Joseph W. Stubbs, MD, MACP, Immediate Past President, ACP, (pictured, left) attended the meeting as ACP International Ambassadors and participated in the API convocation ceremony, where they received Honorary Fellowship in the API. Dr. Stubbs presented a lecture, "The Evaluation and Management of Urinary Incontinence", at the meeting and Dr. Ralston spoke on the topic "Health Reform in the United States".

    ACP Central America Chapter Meeting
    February 11-12, 2011

    The Annual Meeting of the ACP Central America Chapter was held from February 11-12, 2011. Over 500 physicians attended the meeting in Panama City, Panama.

    The meeting's scientific program was filled with excellent speakers, among them two governors: Fred A. Lopez, MD, FACP, of Louisiana, and Michael Sha, MD, FACP, of Indiana. Dr. Sha served as the ACP International Ambassador at the meeting, as invited by Jose Rogelio Mendez, MD, FACP, Governor, ACP Central America Chapter. Dr. Sha delivered talks on osteoporosis, difficulty walking and dementia. Other notable speakes at the meeting included Past Governors of the ACP Central America Chapter, Jorge Motta, MD, MACP, Nestor Sosa, MD, FACP, and Ricardo Reyes, FACP. The program also featured James LeDuc, PHD, Director of the National Laboratory in Galveston, Texas, as a guest speaker on influenza.



    Future World Wide Internal Medicine Meetings

    The current list of Future World Wide Internal Medicine Meetings is available here. Upcoming meetings will be taking place in Bangladesh, Poland, and Japan.



    New International Fellows

    ACP is pleased to announce the following newly elected International Fellows, who were recommended by the Credentials Committee and approved for election by the Board of Regents as of March 1, 2011. They are listed by current location and may have been credentialed through a different Chapter.


    • Khalid A. Alnaqbi, MD, FACP - Toronto
    • David J. Bewick, MD, FACP - St. John
    • Gerald A. Da Roza, MD, FACP - West Vancouver
    • John M. Dornan, MD, FACP - St. John
    • Wayne P. Gulliver, MD, FACP - St. Johns
    • Khaled M. Ibrahim, MD, FACP - St. Catharine
    • Pamela Jarrett, MD, FACP - Quispamsis
    • David R. Marr, MD, FACP - St. John
    • Thomas G. McAvinue, MD, FACP - Moncton
    • Angela M. McGibbon, MD, FACP - Fredericton
    • Martin A. Padmos, MD, FACP - Ottawa
    • Sharon Peters, MD, FACP - St. Johns
    • Paul S. Sohi, MD, FACP - Rothesay
    • Frederick G. Solven, MD, FACP = Frederiction


    • Masafumi Ihara, MD, FACP - Sakyo
    • Masatoshi Kawana, MD, FACP - Tokyo
    • Shin-ichiro Miura, MD, FACP - Fukuoka
    • Mitsutaka Yamamoto, MD, FACP - Kasuya


    • Zeng Xuejun, MD, FACP - Beijing


    • Patricio Lopez, MD, FACP - Santander

    • Harold A. Miranda, MD, FACP - Pereira Risaralda


    • Arshad Akeel Chennur, MD, FACP - Chennai Tamil Nadu

    • Mohd Ibrahim Masoodi, MD, FACP - Kashmir


    • Magnus Gottfredsson, MD, FACP - Reykjavik

    • Sigurdur Olafsson, MD, FACP - Reykjavik


    • Tin M. Hlaing, MD, FACP - Yangon Yangon

    United Arab Emirates

    • Mayank Vats, MD, FACP - Sharjah

    Saudi Arabia

    • Ebtisam Adnan Bakhsh, MD, FACP - Riyadh
    • Hassan Gaafar Mohamed, MD, FACP - Riyadh


    • Akande O. Ajayi, MD, FACP - Ado-Ekiti



    New International Members

    Welcome New Members!

    Welcome and congratulations to the following new ACP Members who were elected from December 1 - January 31, 2011.


    • Tariq Iqbal, MBBS - Nepean
    • Adnan Naeem, MD - Dieppe
    • Mahmud Ahmad Rajabalee, MBBCh - Chatham
    • Jacobus J. Steyn, MBChB - Brockville
    • Lauren E. Tobe, MD - Toronto
    • Philippe Voglimacci, MD FRCP - Duparquet


    • Mauricio Ruiz Carmona, MD - Santiago
    • Carla I. Salvo, MD - Vina del Mar
    • Humberto S. Sotomayor, MD - Santiago


    • Yasuhisa Kuroda, MD - Yachiyo, Chiba
    • Masaya Yamato, MD - Nishinomiya, Hyogo
    • Satoru Yanagisawa, MD - Wakayama
    • Naoki Yanagisawa, MD - Tokyo


    • Jose de Jesus Aguilar Cota, MD - Colima
    • Guillermo Bierzwinsky, MD - Mexico DF
    • Gabriel Cardenas Vazquez, MD - La Piedad
    • Luis Castro, MD - Naucalpan
    • Carlos Alberto Fermin Contreras, MD - Cd Guzman
    • Enrique Gabayet, MD - Estado de Mexico
    • David Gonzalez Mocken, MD - Cd Juarez
    • Jose Angel Gonzalez Sanchez, MD - Ensenada
    • Luis Humberto Gordillo Berber, MD - Morelia
    • Vilda Katherine Handal, MD - Veracruz
    • Ricardo Hernandez Gonzalez, MD - San Luis Potosi
    • Celina Lopez, MD - Guadalajara
    • Jesus O Lozano-Gonzalez, MD - Monterrey
    • Jorge Luis Machado, MD - Tijuana
    • Laura Alicia Madrigal Ruiz, MD - Guadalajara
    • Jose Mandujano Lopez, MD - Queretaro
    • Eduardo Meneses Sierra, MD - Saltillo
    • Raul Mireles Rocha, MD - Zamora
    • Dula Jorgina Ortega Roman, MD - Mexico DF
    • Miguel A Perez, MD - Guadalajara
    • Jose Luis Puga Bucio, MD - Mexico DF
    • Jaime A Quintero Alcaraz, MD - Guadalajara
    • Jahir Ramos Alvarado, MD - Huatusco
    • Carlos S Ramos del Bosque, MD - Saltillo
    • Francisco Ruiz Pons, MD - Cunduacan
    • J Hector Sanchez Mijangos, MD - Mexico DF
    • Andres Torres Gonzalez, MD - Veracruz
    • Alejandro Tovar Serrano, MD - Mexico DF
    • Sergio Varela, MD - Saltillo
    • Carmen Zavala, MD - Mexico DF


    • Josefina M. Fletcher, MD - Panama City


    • Federico E. Elguera Falcon, MD - Bellavista Callao

    Saudi Arabia

    • Faraz A. Niaz, MBBS - Riyadh

    The Netherlands

    • Paul J. Voogt, MD - Cadier en Keer

    United Arab Emirates

    • Syed R. Ali, MD - Al-Fujairah


    • Miguel Salas, MD - Maracay Aragua



    Highlights from ACP Internist and
    ACP Hospitalist

    ACP Internist (formerly ACP Observer) January/February 2011

    • Miserable symptoms mark chronic sinusitis
      Chronic sinusitis, an illness that can feel as symptomatically miserable as congestive heart failure or rheumatoid arthritis, is often misdiagnosed or underdiagnosed. But distinctive clues can lead internists to deliver the right treatment.
    • Speaking of cancer: Tips on how to convey risks to patients
      How physicians express cancer risks to patients determines how they might use that knowledge to make decisions about genetics, family history and potential future screens and tests.
    • When you look, but don't see the diagnosis
      Gradual yet significant change in a woman’s appearance, first noticed by a daughter she hadn’t seen for a year, leads to the diagnosis of a common yet frequently missed ailment. Why hadn’t those who’d seen the woman daily noticed anything? Intuitive vs. deliberative thought processes made all the difference.
    • How many are too many for CT scans?
      As many as one-third of the 70 million imaging tests ordered during the year may not be needed. Experts attempt to determine whether repeated radiation scanning doses could prove potentially yet unintentionally harmful.

    ACP Hospitalist January 2011



      College Corner

      Join us for these international activities at Internal Medicine 2011 San Diego, California - April 7-9, 2011
      International Reception

      Thursday, 4/7/2011
      8:30 - 10:00 p.m.
      Location: Manchester Grand Hyatt - Randle Ballroom

      This reception is open to all international attendees and their guests, as well as other attendees who are interested in meeting with leaders from ACP and internal medicine societies from around the world. Light hors d' oeuvres will be served.

      International Courses
      The Historical Contributions of China to Modern Medicine - MTP 103

      Friday, 4/8/2011
      7:00-8:00 a.m.
      Faculty: Marta Hanson, PhD
      Location: San Diego Convention Center, Room 8

      This Meet the Professor course will discuss the historical contributions of China to Western Medicine. It will combine not only history, much of which is little known to many physicians, as well as a fascinating medical/historical facts.

      This workshop is the third in a planned multi-year series presented under the sponsorship of the International Council, on "Contributions of Multiple Global Cultures to Modern Medicine".

      Lessons Learned from the International Community to Improve Quality of Care - PN 017

      Saturday, 4/9/2011
      11:15-12:45 p.m.
      Moderator: William J. Hall, MD, MACP
      Panelists: Adri Kok, MD, FACP
                    Kiyoshi Kurokowa, MD, MACP
                    Aru W. Sudoyo, MD, PhD, FACP
      Location: San Diego Convention Center, Room 6F

      This panel of international faculty will address quality of care issues from the perspective of their home country, outlining how quality care is delivered, and the challenges of its delivery in countries with poor infrastructure or with few physicians. The panel will highlight major differences in how care is delivered, present models of quality care and outline why these are effective.

      More information on Internal Medicine 2011

      ACP Recruit-a-Colleague

      ACP's Recruit-a-Colleague Program enables you to earn membership dues credits while helping to strengthen the worldwide internal medicine community. The 2011-2012 program runs from April 1, 2011 through March 15, 2012. For more information, please visit http://www.acponline.org/recruitacolleague.

      Reader Submissions

      ACP International welcomes submissions from its readers. If you would like to submit an article for consideration for the newsletter, please send it to the ACP International Office mailbox. Articles submitted for consideration should be formatted in a Microsoft Word document and no longer than one page of 12-point Times New Roman font. Articles about unique health issues routinely treated in your country and humanitarian stories are encouraged.

      Director of ACP International Activities Retires

      Eve C. Swiacki, Director of ACP International Activities, has retired after 32 years of dedicated service to the College. Eve thanks all her international friends for the wonderful memories over the years. We wish you the best, Eve!



      MKSAP 15 Answer & Critique

      Answer: E, Well-fitting support bra.

      Educational Objective: Reassurance and the use of a well-fitting support bra should be the first-line treatment for cyclic mastalgia.

      Critique: This patient most likely has cyclic mastalgia. The pain of cyclic mastalgia is typically dull, heavy, or aching; diffuse; and bilateral; involving the upper outer breast region with radiation to the upper arm and axilla. Noncyclic mastalgia is constant or intermittent. It is usually unilateral and localized within a quadrant. It tends to occur at a later age and is not associated with the menstrual cycle. The cause of cyclic mastalgia is not known. Cyclical breast pain resolves spontaneously within 3 months in 20% to 30% of women. Among women who undergo treatment for breast pain, up to 60% experience recurrent symptoms within 2 years. Reassurance alone is often highly effective in alleviating symptoms and associated anxiety. The simplest first-line recommendations are to wear a well-fitting support bra (underwire for routine use and sports bra for activities) and use local measures (heat, topical NSAIDs) or oral analgesics (NSAIDs or acetaminophen). Changes in diet and lifestyle (avoidance of dietary fat, caffeine, nicotine) and the use of dietary supplements (vitamin E, evening primrose oil) have been advocated by some, but in general, there is inadequate evidence to support these measures.

      In the absence of any focal findings, it is unlikely that this woman has cancer, and specific imaging tests are not required. While some experts recommend mammography in patients with generalized breast pain who are older than 30 years, there are scant outcome research results to support this approach. Age-appropriate breast cancer screening protocols can be followed.

      If the patient’s pain is significant and does not respond to first-line treatments, the antiestrogen tamoxifen or androgenic corticosteroid danazol can be considered as second-line treatment.


      Rosolowich V, Saettler E, Szuck B, et al; Society of Obstetricians and Gynecologists of Canada (SOGC). Mastalgia. J Obstet Gynaecol Can. 2006;28(1):49-71. [PMID:16533457] - See PubMed


Internal Medicine Meeting 2015 Digital Presentations

Internal Medicine Meeting 2015 Digital Presentations

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