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September 2012


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Internal Medicine: Global Perspectives

Roberto Esguerra, MD, FACP
Interim Governor, ACP Colombia Chapter

Colombia is the only South American Country with coastlines on both the Pacific Ocean and Caribbean Sea. Three mighty north-south Andean cordilleras separate the western coastal lowlands from the almost empty eastern jungles, with 54 percent of Colombia’s land but only three percent of the people. Most Colombians are of mixed ethnicity; about 20 percent claim European decent. Native Indians, about one percent of the population, live in eastern jungles. The Andes contribute to the concentration of Colombia’s people into separate clusters. Some live in Caribbean lowlands in cities like Barranquilla and Cartagena; some live in isolated mountain valleys in cities like Cali and Medellin. Bogotá, the capital and largest city, is in a remote mountain basin at 8200 feet. Famers raise world-renowned coffee on the Andean slopes. Colombia sells much of the world’s emeralds and considerable amounts of gold, silver, and platinum and has the continents highest coal production

*source: National Geographic Atlas of the World, Eighth Edition

What inspired you to become a physician?

I was inspired by my family’s tradition of practicing medicine, particularly my father who was a doctor with a great calling towards service and teaching.

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

In Colombia, the role of the internist is not well positioned and is frequently confused with a general practitioner. Sometimes it is looked at as if it isn’t even a specialty.

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

The primary challenge is positioning internal medicine as a medical specialty for adults, to take on a fundamental role in the health system, and for the integrated care of adults.

What are the most common chronic illnesses in Colombia and how do they affect the day-by-day job of an internist?

The most common chronic illnesses are diabetes, arterial hypertension, rheumatic diseases, and cancer. The biggest challenge is figuring out how to moderate the costs of these patients in the health care system.

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

There are not enough young physicians choosing to be internists, but more and more young people are becoming interested in internal medicine.

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

There is strong public debate about our health system; despite having reached universal coverage (97.8%) our system faces big problems related to costs, access to care, and shortage of prevention and promotion. Our current system began in 1993.

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

I think there are some systems, like Canada’s and some other European ones, that have reached a balance between controlling costs and quality and access to care.

What are your responsibilities as the interim Governor of the ACP Colombia Chapter?

To organize the Chapter and reach 200 full members in two years.

What have you found to be the most challenging part of your position? What have you found to be the most rewarding?

The biggest challenge is to consolidate the Chapter and help internal medicine in Colombia improve its status, for that we need to work hand in hand with the Colombian Association of Internal Medicine.

Describe your involvement in establishing the ACP chapter in Colombia.?

Back in the 1980s, we saw that it was very important to establish an ACP Chapter in Colombia and that it would be a huge benefit for internists, for the Colombian Association of Internal Medicine, and for our country. That’s why we worked for the establishment of a Steering Committee that was in place for five years and which I presided over.

You have played a key role in the establishment of an ACP chapter in Colombia, why do you think it is important to have an ACP Chapter in your country?

An ACP Chapter will offer our internists the possibility to utilize all the resources that ACP offers. It will make them aware of important themes related to the global debate about health care systems and current ethical debates, especially those related to end-of-life care. It will help them have a much more universal (and less local) vision of medicine.

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ACP Leaders on the Road: Argentina

Yul Ejnes, MD, MACP

In August, I had the honor of representing ACP at the 14th International Internal Medicine Congress of the Hospital de Clinicas of the University of Buenos Aires. This trip was especially significant for me because my parents emigrated from Argentina to the US two months before I was born, so this was an opportunity for me to reconnect with relatives and bring my wife and two sons on their first visit to this wonderful country. The Congress was attended by 7000 physicians from all over Argentina and Latin America. My two talks were on the “Ten Most Important Papers of 2011” and “The Polymedicated Patient.” Between the talks, I spent time at the ACP table in the Exhibit Hall and met with physicians who were interested in ACP and its products.

The Congress was very similar to our ACP Internal Medicine meeting, with simultaneous sessions offering attendees a choice of topics ranging from updates to focused discussions of specific diseases, research presentations, and clinical skills sessions. Attendees included students, residents, and practicing physicians, many of whom visited the ACP table in the Exhibit Hall and expressed interest in membership and ACP’s products. The Spanish-language Health TiPS and Patient Guides were especially popular.

As I have seen in other parts of the world, physicians in Argentina and the US share similar concerns. Among them are the emergence of medical malpractice litigation, which is increasing defensive medicine; quality of care; and the role of the general internal medicine specialist.

While in Buenos Aires, I was able to visit many of the city’s famous attractions, enjoy its cuisine, especially its world-famous steaks, and attend a tango show. This was my first trip to Argentina in 29 years and was special because of my connection to the country as well as the hospitality that I received from the leadership of the Hospital de Clinicas.

From left: Dr. Guillermo Mendoza, President of the Congress, and Dr. Ejnes.









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New From ACP - MKSAP 16

The new Medical Knowledge Self-Assessment Program® (MKSAP® 16) provides you with the most current and critical information in the core of internal medicine and its subspecialties so you can stay aware of what you need to know as a practicing physician in internal medicine today.

Introduced in 1968, The Medical Knowledge Self Assessment Program® (MKSAP® ) from the American College of Physicians (ACP) has been providing physicians the opportunity to measure their individual knowledge in the broad specialty of internal medicine. Every three years, MKSAP is updated by an editorial team of more than 100 physicians and headed by world-renowned experts. As a result, physicians who use MKSAP are made aware of the most current and critical information in the core of internal medicine and its subspecialties.

Many physicians rely on MKSAP for clinical reference, earning CME credits and MOC points. For ABIM Board preparation it is widely considered the go-to source. MKSAP 16 content covers:

  • Cardiovascular Medicine
  • Dermatology
  • Endocrinology and Metabolism
  • Gastroenterology and Hepatology
  • General Internal Medicine
  • Hematology and Oncology
  • Infectious Disease
  • Nephrology
  • Neurology
  • Rheumatology
  • Pulmonary and Critical Care Medicine

Hospital Medicine content is highlighted across all specialty areas.

Discover gaps in knowledge that may have been otherwise overlooked.
In the current edition, MKSAP 16, you’ll find 1,200 new multiple-choice questions, and hundreds of figures, charts and tables that will enhance your learning experience MKSAP 16’s original and high-quality questions evolve out of case-based studies and patient scenarios based on the latest evidence. Each question will challenge your decision-making, help you find out where you are strong and where you could benefit from more knowledge, and ultimately enhance your patient care.

MKSAP 16 is published in two sections. Part A is now available and Part B will be available December 31, 2012.

For more information on MKSAP 16, or to order your copy, visit http://www.acponline.org/products_services/mksap/16/

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Update Your Knowledge with MKSAP 16 Q & A

A 24-year-old man is evaluated for a 2-hour history of epistaxis, which began after blowing his nose. The bleeding is controlled by placing pressure on the anterior portion of the nose for 3 minutes but then recurs. The bleeding is from the left nostril only. He has severe seasonal rhinitis that has been active recently. He has no history of bleeding, bruising, or clotting, and there is no family history of bleeding disorders. Current medications are loratadine and an intranasal corticosteroid.

On physical examination, he is afebrile, blood pressure is 138/88 mm Hg, and pulse rate is 82/min. Blood pressure and pulse are without significant change from supine to standing positions. He is holding a tissue against his nose. Examination of the left naris with a nasal speculum after the removal of dried blood reveals a small oozing vessel in the septum in the Kiesselbach area. The right naris is clear of blood, and a skin examination demonstrates no petechiae or bruises.

Which of the following is the most appropriate management of this patient?

A. Arterial embolization
B. Cauterization and nasal packing
C. Complete blood count and coagulation studies
D. Uninterrupted nasal pressure for 15 to 30 minutes
E. Urgent otorhinolaryngology evaluation

Click here for the answer and critique.

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Future Worldwide Internal Medicine Meetings

Upcoming meetings will be held in Brazil, Colombia, Spain, and Chile.

A complete list of other Future Worldwide Internal Medicine Meetings is available here.

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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 September 1, 2012. They are listed by current location and may have been credentialed through a different Chapter.

Australia

  • Judy L. Flores, MD, FACP - St. Lucia QLD

Bahrain

  • Jafar Al-Said, MD, FACP - Manama

Bolivia

  • Juvenal Juan Yahuita Quisbert, MD, FACP - La Paz

Brazil

  • Hans Frenando Rocha Dohmann, MD, FACP - Rio de Janeiro

Canada

  • Janet G. Gilmour, MD, FACP - Calgary, Alberta

  • Mark A. Goldszmidt, MD, CM, FACP - London, Ontario
  • Michael A. Levesque, MD, FACP - Niagara On The Lake, Ontario
  • Brian J. Wirzba, MD, FACP - Edmonton, Alberta

India

  • Suresh Ramasubban, MBBS, FACP - Kolkata, W. Bengal

  • Sonaullah Shah, MD, FACP - Srinagar

Italy

  • Massimo Cicchinelli, MD, FACP - Rome

Japan

  • Yaeko Ichikawa, MD, FACP - Tokyo

  • Hisashi Katayama, MD, FACP - Edogawaku Tokyo
  • Akira Mima, MD, FACP - Tokushima/p>

Mexico

  • Jose Flores-Figueroa, MD, FACP - Cuernavaca

  • Isidoro Hoyos C., MD, FACP - Veracruz

Oman

  • Humaid A. Al Wahshi, MD, FACP - Muscat

Pakistan

  • Furqaan Ahmed, MBBS, FACP - Karachi

  • Bikha Ram Devrajani, MBBS, FACP - Hyderabad

Qatar

  • Samar Al-Emadi, MD, FACP - Doha

Saudi Arabia

  • Lina S. Bissar, MD, FACP - Jeddah

  • Khalid M. Ghalilah, MBBS, FACP - Madinah

Taiwan

  • Hsiang-Chung Liu, MD, FACP - Taipei City

United Arab Emirates

  • Saif S. Al-Bedwawi, MBBS, FACP - Dubai

  • Adeel Ajwad Butt, MD, FACP - Abu Dhabi

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Highlights from ACP Internist and
ACP Hospitalist

ACP Internist July/August 2012

  • Baby boomers' health isn't what they expect
    The normal aspects of aging will place extraordinary demands on the health care system as the baby boomers enter their retirement years. Sheer numbers, coupled with high expectations of this population, pose a problem for primary care.

  • Better treatment, low awareness for hepatitis C
    Amid rising rates of long-term hepatitis C infection, particularly among older populations, better treatments are able to treat the condition. But first, patients have to know they have it, and internists have to be able to recognize the diagnosis.

  • Assess statin-associated myalgia on a patient-by-patient basis
    Statin-associated muscle pain is controversial and poorly understood. But the consequence of stopping cholesterol drugs has a much clearer downside. Counsel patients on potential side effects, and let them know that switching is preferable to stopping.

  • Chronic disease model helps improve smoking cessation
    Smoking cessation programs are traditionally treated as discrete, standalone attempts. One program applied dedicated counselors who could form a relationship with the patient over long stretches of time, resulting in better success.

  • Risk of financial abuse in elders should draw internists' attention
    An expert counsels internists to consider screening their elderly patients for financial abuses, from investment scams to pressure from family members. Doctors can partner with financial experts to prevent financial exploitation.

ACP Hospitalist August 2012


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College Corner

Visit the ACP Exhibit Booth at these upcoming meetings!

An ACP Exhibit Booth will be present at the following meetings. Please drop by to pay dues, bring your colleagues to sign up for membership, purchase products, and more.

ACP Brazil Chapter Meeting
Rio de Janeiro, Brazil
October 4, 2012
Website: www.acponline.org/about_acp/chapters/brazil/news_meet.htm

Colombian Association of Internal Medicine Meeting
Cartagena de Indias, Colombia
October 11-14, 2012
Website: www.congresosapmi.com

European Federation of Internal Medicine Meeting
Madrid, Spain
October 24-27, 2012
Website: www.efim2012.org/

World Congress of Internal Medicine 2012
Santiago, Chile
November 11-15, 2012
Email: wcim2012@kenes.com
Website: www.wcim2012.com

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Register Now for Internal Medicine 2013

Join ACP and thousands of your colleagues in San Francisco, California, and transform the way you practice medicine. Internal Medicine 2013 is the only meeting of its kind—combining clinical skills workshops with over 200 scientific sessions to update your knowledge in all facets of internal medicine and the subspecialties.

Refresh your internal medicine knowledge, sharpen your practice management skills, and network with the best and brightest physicians from around the globe. All of this plus a variety of special events including a reception for International attendees make this a meeting not to be missed.

Substantial registration discounts are available for international delegations. Groups of 10 or more are eligible for the special delegation rates. The guidelines require that one person organize the group, provide the registration forms, and submit one payment by check or credit card for the entire group. Not all participants in group delegations are required to be ACP members. Visit im2013.acponline.org/ for more information.








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MKSAP 15 Answer & Critique

Answer: D, Uninterrupted nasal pressure for 15 to 30 minutes

Educational Objective: Manage epistaxis.

Key Point: Anterior nosebleeds almost always stop with consistent pressure for at least 15 minutes.

This patient should be told to apply uninterrupted nasal pressure for 15 to 30 minutes, to not remove the clot or blow his nose, and to temporarily discontinue nasal corticosteroids. More than 90% of epistaxis cases occur at the anterior nasal septum in the Kiesselbach area, the anteroinferior aspect of the nasal septum where multiple arteries anastomose to form a plexus. These episodes of bleeding almost always stop with consistent pressure for at least 15 minutes. Direct causes of epistaxis include nose picking, dry air during winter months, intranasal corticosteroids and decongestants, bacterial or viral rhinosinusitis, and less commonly tumors.

Nasal arterial embolization is reserved for severe refractory epistaxis, which this patient does not have.

The patient would not require cauterization and anterior nasal packing unless the bleeding fails to resolve with at least 15 to 30 minutes of pressure. Nasal packing with or without nasal constrictive agents is effective (60%-80%) but uncomfortable for the patient given that the packing is left in for 1 to 3 days.

Based upon the patient’s history, it is unlikely that he has a bleeding disorder as a systemic cause of his epistaxis and is unlikely to have developed a significant anemia from 2 hours of epistaxis. Laboratory studies are rarely helpful in healthy patients with epistaxis. Even in patients with known bleeding disorders, laboratory studies and coagulation studies are normal in 80% of patients.

It is not necessary to consult an otorhinolaryngologist because the patient reports that the bleeding stops with pressure and the examiner has identified an oozing vessel in the anterior nasal septum. Posterior bleeds warrant referral because they can be difficult to control by application of direct external pressure.

Bibliography:

Schlosser R. Epistaxis. N Engl J Med. 2009;360(8):784-789. [PMID: 19228621]

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ACP JournalWise

Reviews of the World's Top Medical Journals - FREE to ACP Members!
New CME Option: Internal Medicine 2014 Recordings
ACP JournalWiseSM is mobile optimized with optional email alerts! Get access to reviews from over 120 of the world's top medical journals alerting you to the highest quality, most clinically relevant new articles based on your preferred areas of specialty. ACP Members register your FREE account now!

New CME Option: Internal Medicine 2014 Recordings

New CME Package
New CME Option: Internal Medicine 2014 Recordings
Includes 75 of the most popular sessions in internal medicine and the subspecialties. Stream the sessions, answer brief quizzes and earn CME credit. See details.