- ACP Clinical Guidelines
- ACP Leaders on the Road
- Update Your Knowledge with MKSAP 15 Q & A
- Future World Wide Internal Medicine Meetings
- New International Fellows
- New International Members
- Highlights from ACP Internist and ACP Hospitalist
- College Corner
- Email Page to a Colleague
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
Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline Update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society
August 2, 2011 | Volume 155 Issue 3
Recommendation 1: ACP, ACCP, ATS, and ERS recommend that spirometry should be obtained to diagnose airflow obstruction in patients with respiratory symptoms (Grade: strong recommendation, moderate-quality evidence). Spirometry should not be used to screen for airflow obstruction in individuals without respiratory symptoms (Grade: strong recommendation, moderate-quality evidence).
Recommendation 2: For stable COPD patients with respiratory symptoms and FEV1 between 60% and 80% predicted, ACP, ACCP, ATS, and ERS suggest that treatment with inhaled bronchodilators may be used (Grade: weak recommendation, low-quality evidence).
Recommendation 3: For stable COPD patients with respiratory symptoms and FEV1 less than 60% predicted, ACP, ACCP, ATS, and ERS recommend treatment with inhaled bronchodilators (Grade: strong recommendation, moderate-quality evidence).
Recommendation 4: ACP, ACCP, ATS, and ERS recommend that clinicians prescribe monotherapy using either long-acting inhaled anticholinergics or long-acting inhaled beta agonists for symptomatic patients with COPD and FEV1 less than 60% predicted. (Grade: strong recommendation, moderate-quality evidence). Clinicians should base the choice of specific monotherapy on patient preference, cost, and adverse effect profile.
Recommendation 5: ACP, ACCP, ATS, and ERS suggest that clinicians may administer combination inhaled therapies (long-acting inhaled anticholinergics, long-acting inhaled beta agonists, or inhaled corticosteroids) for symptomatic patients with stable COPD and FEV1 less than 60% predicted (Grade: weak recommendation, moderate-quality evidence).
Recommendation 6: ACP, ACCP, ATS, and ERS recommend that clinicians should prescribe pulmonary rehabilitation for symptomatic patients with an FEV1 less than 50% predicted (Grade: strong recommendation, moderate-quality evidence). Clinicians may consider pulmonary rehabilitation for symptomatic or exercise-limited patients with an FEV1 greater than 50% predicted. (Grade: weak recommendation, moderate-quality evidence).
Recommendation 7: ACP, ACCP, ATS, and ERS recommend that clinicians should prescribe continuous oxygen therapy in patients with COPD who have severe resting hypoxemia (PaO2 less than or equal to 55 mm Hg or SpO2 less than or equal to 88%) (Grade: strong recommendation, moderate-quality evidence).
To read the complete Guideline, click here.
ACP Leaders on the Road
Virginia U. Collier, MD, FACP
Virginia Collier, MD, FACP - Santiago, Chile
I was honored to be asked to be an ACP Ambassador to the Chile Chapter meeting in Santiago May 9 – 10, 2011. Because I have strong friendships with the Governor, Maria E. Pinto, MD, FACP, and Jose A. Rodriguez Portales, MD, FACP, a former Governor and member of the Board of Regents, I readily accepted. Their standards are high; I knew that it would be an outstanding meeting and that my husband and I would be treated royally.
Our expectations were exceeded! Upon arrival in Santiago, Dr. Pinto and her husband Augusto greeted us at the airport and took us to our boutique hotel relatively near the meeting site. That evening, we were treated to a welcome dinner at Maria’s house. The party consisted of me and my husband Tom, Virginia Hood, MBBS, MPH, FACP, the current President of ACP and the Leadership Liaison to the meeting, my great friend Isabel Rodriguez (Dr. Rodriguez-Portales’ wife), Rodolfo Armas, MD, MACP, a former Governor of the Chile Chapter, and his wife Patricia MacDonald, along with Dr. Pinto and Augusto. It was a wonderful way to begin our time in Chile. I was impressed with how warmly they welcomed us into their community and how well informed the group was about national and international health care and other issues. I would have liked to be able to speak to them in their native language, but I am not fluent in Spanish. Fortunately, each of them was quite well spoken in English! The highlight of the evening was the traditional Chilean drink, the Pisco Sour. At the end of the evening, I learned that good hosts always keep your glasses full. I will take heed next time I am at a dinner in Chile. Since Dr. Hood, Tom, and I had had previous visits to Santiago, on Sunday, the day before the meeting, Dr. Pinto graciously arranged for us to go on an all day tour of Valparaiso, an old, charming port on the west coast, and Viña del Mar, a tiny seaside resort nearby. We all enjoyed the sites as well as the outstanding sea food and Chilean wine at lunch.
From left: Dr. Collier, Dr. Hood, and Dr. Pinto
The two day meeting was extremely well organized. It was held at a German Club near a German Hospital. The facilities were very good, with space for posters, pharmaceutical exhibits, and two simultaneous lectures. I also enjoyed strolling through the other parts of the building and grounds, which included a beautiful athletic club replete with a German bierstube, tennis courts, and soccer fields. According to Dr. Pinto, there were over 240 participants at the meeting, 73 of them from regions outside Santiago and 5 from other countries (Argentina, El Salvador, Venezuela, USA and Uruguay.) Of the attendees, 78 were associates.
The meeting consisted of talks which were aimed at both general internists and specialists. Each scientific presentation was a half hour in duration. This was a refreshing format, which I felt was easier for both the speaker and the audience. It was clear that all of the Chilean speakers were experts in their fields. I certainly learned a lot! I enjoyed preparing and presenting a talk on The Evaluation of Hematuria, which I gave in a “Multiple Small Feedings of the Mind” format. My presentation on Hospital Medicine appeared to be very timely. Although the hospitalist movement is just beginning in Chile, several hospitalists were important contributors to the meeting. I was particularly gratified to see a young hospitalist utilize an audience response system to work through the issues surrounding a complex hospitalized patient. Two interpreters alternated in simultaneously interpreting my presentations (and Dr. Hood’s) into Spanish.
I also appreciated being a judge at the Medical Student and Resident Poster presentations. Although I think I could have “winged it” alone, Dr. Pinto had efficiently arranged to have an interpreter at my side which certainly allowed me to be a more effective judge. The Indiana Chapter is a “sister chapter” to the Chile Chapter. The ACP Indiana Chapter Award for the best poster in research was presented to the winner of the Associate and Student Poster Session. The Indiana Chapter will also sponsor this winner to attend the ACP Internal Medicine meeting in New Orleans in 2012 to present the poster. I believe that this type of activity will serve to cement the relationships between US and international chapters and should be encouraged and/or formalized more broadly.
I was particularly pleased that Dr. Jose A. Rodriguez-Portales (known to his good friends as either Pepe or “J Rod”), received the ACP Laureate Award. He is an enthusiastic, diligent supporter of ACP. He has helped to make the chapter what it is today and represents all international chapters well at the national level. I was also impressed to see the warm relationship between Masters, Fellows, Members and Associates. The members were clearly engaged in mentoring their young colleagues, which bodes well for the future of the Chile Chapter.
The evening after the meeting, Pepe and Isabel entertained Virginia, Tom, and me for dinner at their beautiful hill side house, fortunately not damaged by the earthquake. This was yet again another example of the warmth and hospitality that we were shown throughout our stay.
My experience as an ACP Ambassador to the Chile Chapter has resoundingly reinforced to me the importance of the commitment that ACP makes to international chapters. Of course, international chapters represent a source of new members. But I believe what is most important about this commitment is the ability to foster personal relationships between internists from around the world. This is leading to mutual respect and to a shared understanding that many of the challenges and opportunities we face are the same. And it is allowing us to learn from each other as we all strive to provide the best possible care for the largest number of our patients.
Update Your Knowledge with MKSAP 15 Q & A
A 36-year-old woman is evaluated in the office for a history of migraine, with and without aura, since age 16 years. She has an average of three attacks each month and consistently experiences an attack 2 days prior to menstruation; this headache is more difficult to treat than those not associated with menstruation. Although she typically obtains pain relief within 2 hours of taking sumatriptan, the headache recurs within 24 hours after each dose during the period of menstrual flow. Sumatriptan, orally as needed, is her only medication.
Results of physical examination are unremarkable.
Which of the following is the most appropriate perimenstrual treatment for this patient’s headaches?
A. Estrogen-progestin contraceptive pill
B. Mefenamic acid
C. Sumatriptan plus naproxen, orally
D. Sumatriptan, subcutaneously
Click here for the answer and critique.
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 Greece, Dominican Republic, Canada, and Brazil.
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 September 1, 2011. They are listed by current location and may have been credentialed through a different Chapter.
Vincent Ho, MD, FACP - Campbelltown NSW
Joao Manoel Theotonio dos Santos, MD, FACP - Sao Jose dos Campo
Valda M. Chijide, MD, FACP - Regina, SK
Vamsee K. Torri, MD, FACP - Regina, SK
Rogelio Altuzarra Hernaez, MD, FACP - Santiago
Carlos Patricio Reyes Abarca, MD, FACP - Santiago
Kenia A. Garcia, MD, FACP - Santiago
Cosmos Rinaldi A. Lesmana, MD, FACP - Jakarta
Dacsaris M. Almengor, MD, FACP - Panama
Diogenes Arjona Plano, MD, FACP - Panama
- Hussain Almatar, MD, FACP - Saihat
Mushabbab Asiri, MD, FACP - Riyadh
Trina Navas, MD, FACP - Caracas
Tarik Saab Saab, MD, FACP - Ciudad Bolivar
Gabriela Ormaechea, MD, FACP - Montevideo
New International Members
Welcome New Members!
Welcome and congratulations to the following new ACP Members who were elected from June 1 - July 31, 2011.
Antigua and Barbuda
Amina Goodwin, MBBS - St. John's
M. Darragh Flannery, MBBch - Parkville VIC
- Hossain Shahid Ferdous, MBBS - Dhaka
- Syed Md Akram Hussain, MBBS - Dhaka
- Iftekhar Mahmood, MBBS - Pabna
- Ajit Kumar Paul, MBBS - Comilla
Raihan Rabbani, MBBS - Dhaka
Ayesha K Peets, MD - Smiths
Gliciane M Barbin, MD - Natal
- Kamal Abu-Rashed, MD - Tecumsceh
- Seraj A Abualnaja, MBBS - Edmonton
- Todd Acheson, MD - Richmond
- Mohammad Al Beshir, MBBS - Toronto
- Meteb M Al Bugami, MBBS - Halifax
- Majid A Al Madi, MBBS - Verdun
- Khalid Al-Saadon, MD - Cornwall
- Ayman Al-Saleh, MBBS - Ancaster
- Maha A Badawi, MBBS - Vancouver
- Mohammed Basheikh, MBBS - Halifax
- Leora Birnbaum, MD - Montreal
- Phoebe Bishara, MD - Canbridge
- Randha A Dahlan, MBBS - London
- Luke Devine, MD - Toronto
- Aadil Dhansay, MBChB - Campbell River
- Kushal J Dighe, MBBS - Toronto
- Annelise Gallien, MD - Bathurst
- Saeedreza Ganjizadeh-Zavareh, MD - Vancouver
- Kaveri Gupta, MD - Winchester
- Paul M Heffernan, MD - Kingston
- Arman Homat, MD - Toronto
- Vishal Joshi, MD - Toronto
- Jacqueline Joza, MD - Montreal
- Edward Z Lee, MD - Vancouver
- Aaron Leong, MD - Montreal
- Elena Liew, MD - Calgary
- Martin Lubanski, MD - Windsor
- Cynthia T Luk, MD - Toronto
- Brindusa Mocanu, MD - Kingston
- Mohammed Ahmed H Qutub, MBBCh - Ottawa
- Sameerah Siddiqui, MBBS - Niagara Falls
- Penny K Tam, MD - Vancouver
- Stephan WB Wardell, MD - Saskatoon
- Chandana Peter Weerasinghe, MD - Vancouver
- Evan Wood, MD - Vancouver
Harold P Yacyshyn, MD - Vernon
- Rafael Araos, MD - Santiago
- Juan Cristobal Celis Carrasco - Santiago
- Claudia H. Olivares, MD - Santiago
- Raul H. Romero Lamas, MD - Iquique, Tarapaca
Leonardo Soto, MD - Santiago
- Anthony A. Okeke, MBBS - Enfield
Ulrich Thalheimer, MD - Exeter
Maria S. Castejon Welchez, MD - Copan
- Arulnithi Ayyanathan, MD - Chennai
- Suchitra Behl, MBBS - New Delhi
- Vivek M Bhalerao, MD - Nagpur
- Mohammad Shameem, MD - Aligarh UP
Sonali Vadi, MD - Ahmedabad
Patrice M. Francis, MD - Kingston
- Masaaki Isaka, MD - Ibaraki
- Junwa Kunimatsu, MD - Tokyo
- Kazuhiko Morii, MD - Himeji, Hyogo
- Soichiro Nagamatsu, MD - Tokyo
- Hiroshi Sato, MD - Chiba
Toru Yamada, MD - Iizuka, Fukuoka
- Fawaz Masalha, MBBCh - Amman
Naeim G Salah, MD - Amman
Omar Gonzalez-Hernandez, MD - Mexico DF
Rosemary T Ikem, MBBCh - Ile Ife, Osun
Ruwaida Nasser Al-Ismaili, MD - Muscat
Muhammad Azeem Khan, MD - Lahore
- Enrique Aurelio Adames Almengor, MD - Panama
- Ana Belen Arauz Rodriguez, MD - Panama
- Ricardo A Lyma-Young, MD - Panama
Enrique Polo, MD - Panama
- Paul Custodio, MD - San Juan
Rose Portia G Zerrudo, MD - Iloilo City
- Ahmad S Al-Ghamdi, MBBS - Riyadh
- Khalid I AlMatham, MBBS - Riyadh
- Saleh H Alharbi, MBBS - Riyadh
Elmahdi Elbadwi Elmahdi, MD - Makkah
Olivier De Senarclens, MD - Geneva
Sandra Groot, MD - Nijmegen
Trinidad and Tobago
Candis A Gomez-Akan, MBBS - Port of Spain
United Arab Emirates
- Abdulla Ahamad, MD - Ajman
- Haytham Alitaha, MBBS - Abu Dhabi
Amal Batoon, MBBS - Abu Dhabi
- Adolfo Acosta Fiol, MD - Caracas
- Jorge Alberto Andujar Garcia, MD - Caracas, Miranda
- Jenny P De Jesus Vielma, MD - Portuguesa
- Maria Gruber, MD - Caracas, Miranda
- Elka Y Lopez, MD - Carabobo
- Rigoberto Jose Marcano, MD - Caracas, Miranda
- Jeannette M Reyes, MD - Caracas DC
Francisco Rodriguez Marante, MD - Bolivar
Highlights from ACP Internist and
ACP Internist (formerly ACP Observer) July 2011
- Promoting literacy to increase adherence
Roughly 80 million Americans navigate health care's complexities with limited health literacy skills. Learn easy steps that help patients understand what they need to do, without formal literacy screening or potentially embarrassing questions.
- Aiding patients' decisions on PSA screening
There are many tradeoffs made when advising patients about whether to routinely screen for prostate cancer using prostate-specific antigen. Amid side effects of treatments and conflicting guidelines from professional societies, physicians and patients must come to a decision. Addressing six points directly and honestly can help.
- Tread lightly: Discussing obesity difficult for internists
Physicians are ill-equipped to dicuss obesity with their patients, a problem created by a lack of training in medical school, no clear guidelines on what screening should consist of, and a lack of confidence that patients would act on such counseling. But done properly, such discussions help twice as many patients lose weight.
- Priming to diagnose a difficult case, avoid representativeness
A patient's deteriorating mental health status points to an underlying cause. But it takes “priming” for an endocrinologist to look for the right diagnosis despite the lack of a prototypical case.
ACP Hospitalist July 2011
- Reducing unnecessary testing
Efforts to test more judiciously represent a dramatic shift in the way physicians use tests to aid diagnosis and guide treatment.
- They read the literature so you don't have to: Update covers important studies of 2010
COPD, stroke and drug choice were among the hot topics in hospital medicine research last year.
- ICU patients suffer symptoms silently
By the time a patient gets to the ICU, his symptoms aren't usually the focus of diagnostics or treatment. But that doesn't mean they aren't still bothering him.
- Which insulin? What drug? When?
Intensity of insulin therapy may get all the press, but there are other dilemmas in inpatient glycemic control.
ACP Venezuela Chapter Governor Honored
The National Board of Directors of the Venezuelan Society of Internal Medicine would like to publicly express its deep appreciation and to convey to Dr. Eva Essenfeld de Sekler, FACP, former President, Honorable Member of our Society, Governor of the Venezuela Chapter of the American College of Physicians (ACP), the most sincere congratulations for having been honored with the award "José María Vargas", by the Universidad Central de Venezuela in recognition of her outstanding academic work, which has contributed to strengthening and promoting the development of research and teaching in the field of medicine in Venezuela.
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.
MKSAP 15 Answer & Critique
Answer: B, Mefenamic acid.
Educational Objective: Treat a menstrually related migraine with an evidence-based modality.
Critique: This patient should be treated with mefenamic acid. She has migraine with aura, migraine without aura, and menstrually related migraine. Her menstrually related headaches are less responsive to acute therapy than are the non–menstrually related attacks, and headache recurs daily throughout menses. The best management for this patient is, therefore, the perimenstrual use of a prophylactic agent. There is evidence that supports the use of mefenamic acid for perimenstrual prophylaxis, with treatment starting 2 days prior to the onset of flow or 1 day prior to the expected onset of the headache and continuing for the duration of menstruation. In this patient, that would mean beginning 3 days before the onset of menstrual flow and continuing throughout menstruation.
The use of combined oral contraceptive therapy (estrogen plus progestin) is contraindicated in this woman because of her history of migraine with aura. Women with migraine with aura are at a two-fold increased risk of ischemic stroke, ischemic myocardial infarction, and venous thromboembolism. The risk of stroke is increased further, up to eight-fold, in women with migraine with aura who use combined oral contraceptive pills
No evidence supports the oral use of either sumatriptan plus naproxen sodium or topiramate for the perimenstrual prophylaxis of menstrually related migraine. Similarly, there is no evidence supporting the subcutaneous use of sumatriptan in this setting. In fact, the higher recurrence rate with the subcutaneous formulation may prove counterproductive.
Key Point: Evidence supports the use of mefenamic acid for perimenstrual prophylaxis of menstrually related migraines, with treatment starting 2 days prior to the onset of flow or 1 day prior to the expected onset of the headache and continuing for the duration of menstruation.
Pringsheim T, Davenport WJ, Dodick D. Acute treatment and prevention of menstrually related migraine headache: evidence-based review. Neurology. 2008;70(17):1555-1563. [PMID: 18427072] - See PubMed
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