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March 2012


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Internal Medicine: Global Perspectives

Jose A. Rodriguez-Portales, MD, FACP
ACP Board of Regents Member, 2006-2012

Chile is one of South America's most stable and prosperous nations. It has been relatively free of the coups and arbitrary governments that have blighted the continent. The country had Latin America's fastest-growing economy in the 1990s and has weathered recent regional economic instability. The authoritarian Pinochet-era constitution has been revised and the judicial system overhauled. It faces the challenges of having to diversify its copper-dependent economy - it is the largest world producer - and of addressing uneven wealth distribution. Chile is a multi-ethnic society, including people of European and Indian ancestry.

*source: BBC News

What inspired you to become a physician?

It began with a strong desire to learn how the world works, beginning by the study of man. To learn about man, I thought that I would start by studying the human body. Prompted by a feeling of bewilderment when facing suffering and death, I thought I needed to know more about diseases and ways to cure them. I thought I might help to alleviate suffering by explaining to myself and to others how these things come to be. I think that medicine is one of the most humane activities. It also provides an interest for the humanities as products of the acts of man that help to shape his environment and thus influence his health.

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

The role of the internist in Chile has been evolving. When I was a medical student the internist was like an orchestra conductor who was respected because he was the one who could better integrate medical knowledge, challenge the subspecialists, and produce the most sensible and balanced treatment options. A few years later, the overwhelming growth of the subspecialties made it very hard for the undifferentiated internist to continue in this role, while the people in general began ascribing every symptom or disease to a different group of subspecialists and consulting them instead of the internists. The subspecialists have the last say and that, in combination with better recognition in terms of prestige and monetary rewards, has been attracting young physicians to the subspecialties rather than to undifferentiated internal medicine. However, there are still many subspecialists who keep their primeval interest for internal medicine.

In Chile there are internists working at all levels. Their role is best described as consultants at the secondary care level for outpatients, as attending physicians and as consultants for other specialists in hospitalized patients with complex, multidisciplinary problems. Still, more than half of graduates from an internal medicine residency choose to go into a subspecialty.

As for the public, the difference between a non-specialist primary care doctor, a family doctor, and an internist is somewhat blurred. To many, an internist is a kind of general practitioner that can provide a first approach and treat common problems but whose opinions have to be confronted with those of a subspecialist in the area in question.

Are there special challenges facing internists in Chile? What are your thoughts on how to meet those challenges?

As in most countries, the challenge for internists is to recover the prestige of the profession and stance in terms of the care of patients. This can be done by several ways, among which I would mention the hospitalist movement, the mastery of evidence-based care, the concern for quality of care across all specialties, the use and promotion of high value, cost-conscious care, and the exploration of new models of patient care, such as the patient-centered medical home.

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

According to published data, about one third of physicians applying for specialization in Chile between 2007 and 2010 chose to specialize in internal medicine. However, as I mentioned previously, more than half of them will eventually continue on to a subspecialty. Among the reasons invoked for choosing internal medicine, the most frequent ones are the identification of the specialty with the applicant’s concept of medicine as a profession, the comprehensive approach typical of internal medicine, the deeper involvement of internists with patients, and the quest for more global knowledge. The barriers usually encountered are a more demanding lifestyle, particularly for women, lower expectations of income, and little recognition for intellectual work in the profession. There is always the concern that there is not enough training centers and programs to meet the demand.

Is there a public debate about your country’s health care system?

There is a vigorous debate about the health care system in Chile. Prior to 1973, the public health care system had been designed after the British model. But with few resources, excessive centralization and such chaotic results, the House of Representatives produced a statement that year comparing the health care system in Chile to that of a country in a state of war invaded by a foreign power. Since then a more rational administration has been put in place, the unified and centralized national health care system was broken down into 13 semi-independent regional systems with the ability to manage their own budgets according to their needs. Primary care was transferred to the municipalities or city councils as a means to obtain more involvement of the community. The central authority’s role was one of supervision, setting of priorities, goals, performance indicators, elaboration of guidelines and programs and design of health policies. In parallel, the private sector was given a strong impulse by allowing the creation of health maintenance organizations and managed care programs. Hundreds of different health care plans are offered to the public. Investment in health care increased significantly in the private sector, and new hospitals with top-of-the-line technology have multiplied throughout the country.

By law, every salaried worker must set apart a seven percent of his or her salary for health insurance and is free to choose the insurer, public or private. The unemployed, indigent, aliens, persons under 18 or pregnant are covered by public funds. The single public insurer gets this seven percent from those with lower incomes that constitute over 70 percent of the population and offers in exchange medical care at public hospitals and clinics, with no exclusions or pre-existences and cannot discharge or refuse entry to anyone. Although improved, the public sector’s facilities and quality of care are deemed inferior to those in the private sector. The private sector captures between 20 to 30 percent of the population that signs up for a wide variety of plans with different coverage and copayments. Within the private sector, you can be denied access because of pre-existing conditions, discharged if your treatment is too costly, and the price of your plan increases as you grow older. Total expenditure on health in Chile reaches 8.2 percent of the gross domestic product (GDP).

The debate about health care centers on the balance between the public and private sectors. For some, the public sector must be strengthened by raising taxes and increasing government spending. The responsibility for primary care should be removed from the city councils and returned to the Ministry of Health. All kinds of subsidies or grants for the private sector should be severed. While others believe that the private sector is doing a good job, health care is better there, and more people should be helped or encouraged to switch from the public to the private sector.

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

I think that there is no such thing as a perfect health care system. It is extremely difficult to balance access, quality of care, and financing in the right proportions. In the United States, quality of care may excel but access is not universal and financing is problematic. In Chile access is universal, but quality of care and financing tend to be insufficient. The British health care system, which is a source of inspiration for Chile and other countries, has a wider access to basic medical care but difficult access to specialized care, including long waiting lists and soaring expenditures. Also, it is difficult to compare health care systems in abstract since they have to work in communities with very different economic, cultural, demographic and social backgrounds.

What could other countries learn from the health care system in Chile?

As mentioned, it is impractical to translate what works in one country to another where the same design may prove to be a total failure. However, Chile has to exhibit outcomes in selected health indicators that at are as good as or better than in many well developed nations and that excel within the Latin American context, with lower expenditures. For instance, life expectancy is 82 years for women and 76 for men; the under five mortality rate is only nine per 1000 live births, six-fold lower than the global average; maternal mortality is 26 per 100,000 live births, almost ten-fold lower than the global average. Infectious diseases are not among the frequent causes of death as are cardiovascular diseases and cancer, as in the developed world.

In view of limited resources, in 2005 a law was passed that ensured universal access to quality and timely health care for all patients who have one or more of 69 designated clinical conditions. The financing of this program came from a one percent increase in the value added tax for all taxpayers. Among these conditions are hypertension, diabetes mellitus, depression, rheumatoid arthritis, oral health in children and the elderly, various types of cancer and many others. There are evidence-based guidelines to be followed in the treatment of patients with these conditions, and if the public health system cannot meet the deadlines established for treatment, the patient is transferred to the private sector with the difference in cost covered by the program.

Describe your involvement with ACP.

My involvement with ACP began as a young physician when a chapter was established in Chile. I was invited to join as a member and after two years was promoted to Fellow. In 1989 I applied and obtained an ACP-sponsored Latin American Fellowship which allowed me to spend three months visiting and working with top specialists at the NIH, Mayo Clinic, and MD Anderson Hospital. In 2000, I was asked to run for Governor of the Chile Chapter, based on the fact that I was at that time President of the Chilean Society of Internal Medicine, and the tradition was that former Presidents were asked to run for Governors as a way to maintain smooth relations between both institutions. As Governor my views about medicine began to change to a more global perspective. It was gratifying to meet so many interesting people committed to fostering excellence and professionalism in the practice of medicine. For three years, I was a member of the International Subcommittee and helped carry on the College’s international activities. A year after my term as Governor had ended; the proposal to run for Regent came to me as a totally unexpected invitation. My astonishment was even greater when I was told that I had been elected in 2006 and again in 2009 for a second term. During these years I have improved my understanding of the College and the important role it plays not only within the United States but as the premier society of internal medicine in the world. As a Regent I have participated in discussing the College’s strategic planning and setting of priorities and goals. I have been invited as a College representative or invited speaker to chapter meetings in Venezuela, Panama, Maryland and Alaska, chaired the College’s International Council since 2009, and have been a member of the Bylaws, Marketing and Publications, and the Credentials Committees.

How has ACP’s international presence changed you since you began your involvement with ACP?

During its almost 100 years of existence, ACP has always had an interest for international activities albeit with varying intensities and emphasis. Due to the US presence in the Canal Zone, the Panama Chapter was the first one to open outside the mainland. Canada and Mexico followed suit followed by Chile, Brazil, and Venezuela. In the late nineties the emphasis on international expansion dampened and for several years no new chapters were created, although there were a few thousand scattered members and Fellows without chapters around the world. Only a few years ago the interest for international expansion has been rekindled and currently the rate of growth of international membership has exceeded that of domestic membership. A powerful and well organized chapter has been established in Japan, with over 1,000 members, a new Chapter was formed in Saudi Arabia and several others are on the waiting list. During the Internal Medicine meeting (formerly Annual Session) well over 500 international physicians attend and hundreds march during the Convocation Ceremony to be inducted as Fellows. Consistent with this growth, the International Subcommittee was upgraded to a Council reporting directly to the Board of Regents. Discussions during the Board of Regents planning retreats have emphasized that the College’s priorities and goals are valid for international as well as for national activities.

Right now there is a growing awareness that international expansion of the College has an immense potential, as interaction with densely populated countries in Asia continues to grow and the role of the College as the premier synthesizer and distributor of medical education and information becomes more apparent.

What are some of the most gratifying international developments at ACP?

Seeing so many internists from around the world sharing the mission and goals of the College has been a very gratifying development. This can be experienced first hand during the International Reception, held annually during the Internal Medicine meeting. Here the College’s leadership, as well as many US Masters, Fellows and members, share in a joyful and familiar mood with their peers from all over the globe. The Japan Reception is also a particularly significant event in which we all enjoy fine courtesy and camaraderie.

What is your vision of ACP in 10 years from an international standpoint?

My wishful thinking is that within 10 years ACP will have at least 10% of its members living outside of the United States. New chapters will hopefully arise in India, the Philippines, maybe China, Colombia, Argentina and Peru while the existing ones will thrive with an expanding membership that will use and appreciate better all the products and services that the College has to offer. I hope too that there will be a continuous presence of an international regent on the Board of Regents. However we must be cautious that the present emphasis does not slacken.

Why should ACP continue to expand internationally?

Medicine recognizes no frontiers. There is a universal appeal to help the sick and the suffering, and physicians are well prepared to professionally assume that task. Collaboration is one of the ethical duties of physicians. The ACP has a wealth of resources, publications and educational materials from which all internists could benefit, no matter where they are located. The problems that internal medicine faces are very similar around the world and ACP is in a good position to provide a forum where international internists can convene to discuss their problems and solutions.

Please share a memorable ACP international experience.

One of the most memorable experiences is the International Forum, in which the President of ACP along with the CEO and Officers get together with the Presidents of the National Societies of Internal Medicine attending the ACP’s annual meeting to discuss topics such as quality of care, workforce required, and others that are common to many countries. There you get the feeling that medicine is universal and that the ACP is a point of encounter for all of them.

What are your general reflections on ACP International expansion?

To summarize, I think that ACP’s international expansion is promising, necessary, and beneficial and therefore should be encouraged and stimulated by the College’s current and future leaders.

ACP thanks Dr. Rodriguez-Portales for all his years of service to the College!

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ACP Leaders on the Road: India

Tanveer Mir, MD, MACP and Virginia Hood, MBBS, MPH, FACP

Pictured at left: Dr. Mir and Dr. Hood

APICON 2012, the 67th Annual convention of Association of Physicians of India (API) was held at the Convention Center of the Science City, Kolkata, India from January 12th-15th 2012. Dr. Virginia Hood, ACP President and I attended the convention as ACP Ambassadors.

India is the seventh-largest country by geographical area, the second-most populous country with over 1.2 billion people, and the most populous democracy in the world. Bounded by the Indian Ocean on the south, the Arabian Sea on the south-west, and the Bay of Bengal on the south-east, it shares land borders with Pakistan to the west; China, Nepal, and Bhutan to the north-east; and Burma and Bangladesh to the east. Home to the ancient Indus Valley Civilization and a region of historic trade routes and vast empires, the Indian subcontinent was identified with its commercial and cultural wealth for much of its long history. Four of the world's major religions—Hinduism, Buddhism, Jainism, and Sikhism—originated here, whereas Zoroastrianism, Christianity, and Islam arrived in the 1st millennium CE and also helped shape the region's diverse culture. Gradually annexed by and brought under the administration of the British East India Company from the early 18th century and administered directly by the United Kingdom from the mid-19th century, India became an independent nation in 1947 after a struggle for independence that was marked by non-violent resistance and led by Mahatma Gandhi. The Indian economy is the world's tenth-largest by nominal GDP and third-largest by purchasing power parity (PPP). Following market-based economic reforms in 1991, India became one of the fastest-growing major economies; it is considered a newly industrialized country.

India has been well-known for the healing arts since ancient times. Ayurveda, ‘the knowledge for long life’ is a system of traditional medicine native to India and a form of alternative medicine. In Sanskrit, words ayus, means ‘longevity’, and veda, means ‘knowledge’ or ‘science’. The earliest literature on Indian medical practice appeared during the Vedic period in India, in the mid-second millennium BC. Over the following centuries, Ayurveda practitioners developed a number of medicinal preparations and surgical procedures for the treatment of various ailments. Current practices derived from Ayurvedic medicine are regarded as part of complementary and alternative medicine. Along with the traditional healing arts, medical education developed in India over the past millennium, based on the British system of medical education. India has a combination of state and private medical schools. The Medical Council of India (MCI) is the accreditation body for medical education in India. The MBBS (Bachelor of Medicine and Bachelor of Surgery) is a four and a half years-long course, and is followed by one year of mandatory rotating residential internship. Postgraduate specialty training is three years in duration and two-year fellowship programs in medical sub-specialties are offered in select institutions. India exports a large number of physicians to the US and the rest of the world.

The Indian city of Kolkata, on the river Hooghly, retains the aura of days long gone, weaving the past and the present, the intense and the fun-loving into a charming fabric. Home to four Nobel laureates - Ronald Ross, Rabindranath Tagore, Mother Teresa and Amartya Sen, Kolkata is considered the center of intellect and human values, where many modern Indian movements began in art, cinema, theatre, science, and industry. India's quest for freedom began here. Kolkata is the gateway to Eastern India, a city with a rich heritage and bustling streets. In 1690 Job Charnock of the East India Company came to the bank of the river Hooghly and took the lease of the three villages including Kolkata as a trading post of British East India Company. Warren Hastings, the first Governor-General of India, made it the seat of the supreme courts of justice and the supreme revenue administration, and Kolkata became the capital of British India in 1772. By 1800 Kolkata had become a busy and flourishing town, the center of the cultural as well as the political and economic life of Bengal.

APICON 2012 was held in the Science City and convention center, the largest science center in the sub-continent. The Convention Centre of Science City is the most sought after destination for conventions, meetings, events and cultural programs. APICON 2012 was registered at 8,000 attendees. Attendees were general internal medicine specialists and super-specialists who are a part of the 17,000 members of Association of Physicians of India. There were some in-training physicians including fellows, who participated in the poster sessions. Some local medical students were attending the conference as well. Several Deans from local and other States from India were present. They constitute the academic medical leadership of the Indian College of Physicians (ICP).

The audio-visual was excellent in the main auditorium at the Kolkata Science Center and the program was entirely in English. PowerPoint slides of all speakers and AV support was good. Of interest was the simulcast of the sessions outside the halls for people to see what was being delivered inside. ACP was well-recognized and known to APICON members. Physicians from the private practice area seemed to comprise the majority of attendees. The presence of faculty from private and state medical schools, post-graduate IM Programs and sub-specialty attendees, and private practitioners produced a diverse mix at APICON. Some wanted life membership for one initial fee as is the custom for Indian medical organizations. Expense is a problem for those in public institutions.

Dr Virginia Hood and I met with the leadership of the API and ICP during our stay. The inauguration festivities included classic Indian dances and speeches from visiting dignitaries. We met with several dignitaries of APICON and they included immediate past president Professor Banerjee, president Professor Sandhya Kamath , president elect Dr A. Muruganathan, and Vice President Dr. Shashank Joshi. Dr. Joshi is a US trained Endocrinologist, and a Fellow of the college. Dr. Hood was recognized as the president of ACP at the official inaugurations. Dr. Hood and I participated in the convocation and marched with the ICP, and were given honorary fellowships in API. The audience was keen about ACP activities in India.

Dr. Mir and Dr. Hood stand together with API leadership









We look forward to the ongoing relationship with APICON. We look forward to seeing APICON dignitaries at IM 2012 in New Orleans.

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ACP Leaders on the Road: Panama
Central America Chapter Meeting

Robert G. Luke, MD, MACP

Pictured at left: Dr. Robert Luke

Recently, I had the privilege of representing the College at the Central America Chapter meeting. The meeting was held February 3-4, 2012 in Panama City, Panama. The focus of the two day program was on cardiology and nephrology. Two sitting Governors, Drs. Richard K. Kasama (southern New Jersey) and Dr. Alex Gonzalez (western Pennsylvania) also contributed to the program. Howard Weitz, Chief of Cardiology at Jefferson University – and a real advocate also for Internal Medicine and the college – also was a lecturer.

Panama is a small but important country on the isthmus between North and South America. Its population is 3.5 million and it is about the size of South Carolina. Panama City (in which half of the population of the country lives) is in a period of rapid economic growth, international investment and is sprouting skyscrapers. It is certainly a vibrant city. The same adjective applies to its ACP Chapter, its Governor, Jose Mendez, and his Council. He has garnered great enthusiasm in the Panamanian ranks of practitioners, academics, residents and medical students.

Standing room only in a meeting room accommodating 500 people was the rule at the meeting. Medical students and residents were vigorously and numerously involved in the meeting and the Resident with the winning poster and Jeopardy team will be coming to the ACP Internal Medicine meeting this April in New Orleans.

In a small country like Panama, the ACP Chapter can more easily be the professional home for subspecialists as well as generalists. As in my ACP experience in all of Central and South America, our hosts provided a wonderful and warm social program. Our wives enjoyed sightseeing and entertainment every day. All of us visited a nearby lock on the Panama Canal, had dinner with a canal pilot and learned about the deepening of the canal, to be completed in 2014 and then handle all the new larger container ships traveling to the east coast of the United States.

How would you like to have weather always in the 70 – 80 degrees Fahrenheit range? Many US retirees appear to be taking advantage of this benefit, as well as off – so far – a lower cost of living. Tourism is certainly on the increase and we had a really interesting tour of the old “colonial” town, which is being reconstructed. Finally, we visited the beach about an hour away from Panama City. I believe that our wives, surprisingly, did some shopping too. No, I did not buy a Panama hat, just a cap from the Panama Canal.

Wendy Rivera was very busy with our educational products and with physicians inquiring about membership including a new affiliate status for family physicians (a category initiated at the instigation of the Central America chapter).

The ACP is alive and well in Panama!

Pictured at left: Dr. Jose Mendez, Governor, ACP Central America Chapter, Dr. and Mrs. Luke, and Dr. Aron Benzadon-Cohen, Governor-elect, ACP Central America Chapter





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Update Your Knowledge with MKSAP 15 Q & A

A previously healthy 42-year-old woman is evaluated in the emergency department for the sudden onset of a severe occipital headache during defecation 8 hours ago, followed by two episodes of vomiting. She reports no neck stiffness or neurologic symptoms. Her mother and two sisters have a history of migraine.

On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 148/88 mm Hg, pulse rate is 90/min, and respiration rate is 20/min. The patient is in obvious distress as a result of the pain. No evidence of meningismus, papilledema, or focal neurologic signs is found.

Cerebrospinal fluid examination reveals a normal level of protein and glucose and no leukocytes or erythrocytes.

A noncontrast CT scan of the head shows no abnormalities.

Which of the following is the most appropriate next step in management?

A. Admission to the hospital for overnight observation
B. Administration of sumatriptan, subcutaneously
C. CT angiography of the head and neck
D. Repeat lumbar puncture

Click here for the answer and critique.

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Advancement to Fellowship Consultations at ACP Internal Medicine 2012

New at Internal Medicine 2012! Advancement to Fellowship Consultation Sessions will be offered on Thursday, April 19th from 10:30 - 11:15 a.m. and Friday, April 20th from 3:45 - 4:30 p.m. at the Membership Booth in the ACP Resource Center. Each of session will be led by CAPT. Jeffrey B. Cole, MC, USN, FACP, Chair of ACP’s Credential Committee. Spanish-speaking staff from our International Activities office will be present at both sessions to translate information and questions. Fellowship application materials will be available for all eligible members.

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Future Worldwide Internal Medicine Meetings

The current list of Future Worldwide Internal Medicine Meetings is available here. Upcoming meetings will be taking place in Paraguay, Japan, and Australia.

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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, 2012. They are listed by current location and may have been credentialed through a different Chapter.

Canada

  • David R. Anderson, MD, FACP - Halifax, NS

  • Belluru S. Satyanarayana, MD, FACP - Bathurst, NB
  • Mark G. Whalen, MD, FACP - Campbellton, NB

Chile

  • Roberto Daniel Jalil Milad, MD, FACP - Santiago

  • Carlos Alberto Zuniga San Martin, MD, FACP - Conception

Egypt

  • Amgad E. El-Agroudy, MBBCh, FACP - Mansoura

India

  • A. Muruganathan, MD, FACP - Tirurpur

Japan

  • Hitoshi Hasegawa, MD, FACP - Akita

  • Kazutoyo Tanaka, MD, FACP - Fukuoka City

Jordan

  • Mazen A. Asayreh, MBBS, FACP - Amman

Mexico

  • Ruben Antonio G. Gomez Mendoza Sr., MD, FACP - Mexico DF

Pakistan

  • Ahsan Azhar, MD, FACP - Lahore

  • Syed Muhammad Irfan, MBBS, FACP - Karachi
  • Ossam Khan, MBBS, FACP - Peshawar
  • Saeed Ahmed Mahar, MBBS, FACP - Karachi

Saudi Arabia

  • Mohammed A. Alsheef, MBBS, FACP - Riyadh

  • Arshad M. Mian, MD, FACP - Riyadh

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Highlights from ACP Internist and
ACP Hospitalist

ACP Internist February 2012

ACP Hospitalist February 2012


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College Corner

New Membership Category

A new type of membership called Physician Affiliate membership is now available to non-internists with credentials to practice. To qualify, a candidate must have graduated from a medical school listed in the International Medical Education Directory (IMED). Benefits include reduced membership dues, online access to ACP's premier publications, and significant discounts on educational meetings and products. Physician Affiliates will not be allowed to vote, hold office, or acquire Fellowship.  However, they may be allowed to serve on any committee that currently has open seats for nonmembers. For more information, or to apply online, visit www.acponline.org/membership/join/international/.

2011 Chapter Excellence Awards

We are happy to announce that six international chapters are in receipt of the 2011 Chapter Excellence Award. These are the Brazil, British Columbia, Central America, Chile, Japan, and Mexico Chapters. These chapters are in receipt of this award because they have made great strides in chapter management in numerous ways. These include such activities as formulating an effective Governor’s Council and committees, communicating frequently with their membership, providing educational opportunities, recruiting and advancing members and celebrating their membership through local awards. Congratulations to these chapters on a job well done!

Upcoming Membership Year

ACP's membership year runs from July 1 to June 30 each year. We will be sending out our first dues notifications for the upcoming year via email starting on March 27. We urge you to pay your dues early so as to ensure continuation of your benefits. Dues for the upcoming membership year will not increase.

If you continue to receive print publications, you have the opportunity to convert to an online only membership when you receive your dues bill. This option is only available to our international physicians and provides a reduction in annual dues and rates are dependent upon your country of residence. Please visit www.acponline.org/dues for specific information on dues.

Be Counted

This fall, for the first time in 15 years, ACP will be launching a revised 2012 Census questionnaire to help us better understand membership. Look for the link to complete the brief survey online. It is vital that as many members of ACP as possible are counted.

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MKSAP 16 Answer & Critique

Answer: C, CT angiography of the head and neck.

Educational Objective: Manage a thunderclap headache.

Critique: This patient should undergo CT angiography of the head and neck. She has experienced a thunderclap headache, which is a severe and explosive headache that is maximal in intensity at or within 60 seconds of onset. Every thunderclap headache must be immediately evaluated to detect potentially catastrophic conditions, especially subarachnoid hemorrhage. Most of the other causes of thunderclap headache, such as an unruptured cerebral aneurysm, a carotid or vertebral artery dissection, cerebral venous sinus thrombosis, and reversible cerebral vasoconstriction syndrome, can be excluded by noninvasive angiography. Therefore, CT angiography of the head and neck is the most appropriate next step in management. CT angiography can detect unruptured aneurysms as small as 3 mm in diameter and thus is adequate to exclude this diagnosis. Magnetic resonance angiography (MRA) would also be appropriate in this setting. Both CT angiography and MRA can be performed with a venous phase to exclude cerebral venous sinus thrombosis. Given that most causes of thunderclap headache can be excluded by such noninvasive angiography and that prior cerebrospinal fluid analysis has shown no evidence of a subarachnoid hemorrhage in this patient, conventional cerebral angiography, in which a catheter is inserted into a large artery and advanced through the carotid artery, is unnecessary.

Because of the potential for neurologic morbidity associated with several of the causes of thunderclap headache, admission for observation without evaluation of the cerebral vasculature would not be the best management option.

Similarly, treatment with a vasoconstrictive drug, such as sumatriptan, would not be appropriate until the other causes of thunderclap headache have been excluded. Drugs with the potential to constrict extracranial and intracranial cerebral vessels can precipitate or exacerbate the cerebral ischemia that may be associated with arterial dissection and reversible cerebral vasoconstriction syndromes.

Although it may take up to 6 hours for subarachnoid blood to sediment into the lumbar thecal sac, this patient’s first lumbar puncture occurred more than 8 hours after the onset of symptoms. Repeating the lumbar puncture would, therefore, be unnecessary.

Key Point: Thunderclap headache is a potential neurologic emergency that requires urgent imaging of the cerebral vasculature with either magnetic resonance or CT angiography after a noncontrast CT scan of the head and a lumbar puncture have excluded subarachnoid hemorrhage.

Bibliography

Schwedt TJ, Matharu MS, Dodick DW. Thunderclap headache. Lancet Neurol. 2006;5(7):621-631. [PMID: 16781992] - See PubMed

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MKSAP 16 Holiday Special: Save 10%

MKSAP 16 Holiday Special:  Save 10%

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Maintenance of Certification:

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Maintenance of Certification: What if I Still Don't Know Where to Start?

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