March 2007 E-Newsletter

Win a 128 MB Flash Drive from ACP! Contest Question for March

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If you are among the first 30 respondents to answer the following question correctly you will receive a 128 MB flash drive from ACP. E-mail your answer to ImpactContest@acponline.org. The correct answer to March’s contest question will be included in the April issue of IMpact. You must be an ACP Medical Student Member to be eligible to win. Contest winners are not eligible to win again for 4 months.

A 70-year-old woman comes to your office for a routine annual physical examination. She reports mild effort intolerance over the last several months, but has continued her usual active lifestyle. She has a history of hypertension that is well controlled with diuretic therapy. Findings on physical examination and electrocardiography are consistent with atrial fibrillation, with a ventricular rate of 100/min, but were otherwise normal. Echocardiogram shows a left ventricular ejection fraction of 55%, with left atrial enlargement, mild mitral annular calcification, and mild mitral regurgitation. She has no history of stroke or ulcer disease.

Which of the following would be the most appropriate therapy for this patient?

( A ) Aspirin and a β-blocker
( B ) Aspirin and amiodarone
( C ) Aspirin and digoxin
( D ) Warfarin and a β-blocker
( E ) Warfarin and amlodipine

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Answer for February Contest Question

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Click here to see February’s question.

Answer to February Contest Question: D

This patient has two risk factors that favor the use of an angiotensin-converting enzyme (ACE) inhibitor or possibly an angiotensin receptor blocker (ARB): diabetes mellitus and an elevated serum creatinine. The HOPE trial in diabetics (MICRO-HOPE) and other data in patients with hypertension show the benefit of an ACE inhibitor for reducing the incidence of vascular events in patients with diabetes. The LIFE trial showed a reduction in the incidence of clinical events in patients with hypertension and diabetes who were treated with losartan (an ARB) compared with those who were treated with atenolol. Furthermore, both of these classes of agents have been shown to slow the progression of renal disease in patients with diabetes and proteinuria. There has been no progressive trial comparing the two classes of agents. Because they may sometimes worsen the serum creatinine level they must be initiated carefully in patients who have azotemia. Dihydropyridines are effective antihypertensive drugs and reduce the risk of stroke. However, there is no mandate to use these agents as first-line therapy. Both ÿ-blockers and calcium channel blockers are appropriate agents for use in patients with diabetes, but not as first-line therapy. Similarly, randomized trials strongly support the efficacy of thiazide diuretics in patients with hypertension (ALLHAT); however, these agents offer no specific benefits in patients with diabetes. Clonidine offers no vascular or renal protection.

References

Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000;342:145-53.

Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet 2000;355:253-9.

Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345:861-9.

Lindholm LH, Ibsen H, Dahlof B, Devereux RB, Beevers G, de Faire U, et al. Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002;359:1004-10.

Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288:2981-97.

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Medical Student Perspectives: What is Osteopathic Medicine?

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It is not uncommon to still hear the question, “How is a DO (Doctor of Osteopathic Medicine) different from an MD (Doctor of Medicine)?” or, “What exactly is a DO?” These are some of the recurring questions many of my osteopathic colleagues and I hear on a regular basis. When these questions are raised, they present perfect opportunities to talk more about our profession and educate patients and other medical professionals about osteopathic medicine.

Andrew Taylor Still, MD, DO, founded osteopathic medicine in 1874 after experiencing significant despair with 19th century medical therapies. His disillusionment peaked after medical failure touched his own life as he watched three of his children die from spinal meningitis. Dr. Still felt many medical therapies such as bloodletting, and mercury preparations such as calomel, were ineffective and ultimately harmful therapies. As a result, he pioneered the concept of body unity. He recognized the importance of preventive health and the ability of the body to heal itself. Lastly, he emphasized the role of the musculoskeletal system as a key element in good health.

In 1892, Dr. Still founded the first osteopathic school called the American School of Osteopathy, which is now called the Kirksville College of Osteopathic Medicine. Dr. Still’s initial aim was to provide an education based in manual manipulation of the musculoskeletal system. Shortly thereafter, a full medical education program was implemented. As a result of the 1910 Flexner Report, sweeping educational requirements took place in many DO and MD granting institutions and the modern medical education system was born.

Today, there are 23 osteopathic medical schools in the United States. Osteopathic schools emphasize training primary care doctors with an emphasis on treating the “whole” person, not just a patient’s symptoms. Clearly, all clinicians, whether they are MDs or DOs, care for the entire patient, but osteopathic schools emphasize and integrate this philosophy into all aspects of the curriculum. The scientific and evidence-based training for osteopathic students is very similar to the training received by allopathic (MD) students and upon graduation, DOs are fully licensed physicians in all 50 states. In addition, osteopathic medical students receive training in Osteopathic Manipulative Medicine (OMM), where they learn to diagnose and treat with their hands using a number of different treatment modalities.

After graduation, DOs enter osteopathic and allopathic residency programs in all fields of medicine and surgery. Currently, osteopathic students are being highly encouraged by the American Osteopathic Association (AOA) to consider training opportunities that will better prepare them to work as primary care providers in both rural and urban underserved parts of our country’s health care system.

The history of osteopathic medicine is relevant and interesting, but the future is where the focus lies for young osteopathic medical students. Increasing public awareness and a deepening of professional camaraderie between MDs and DOs will continue to play a positive role in building and maintaining superior healthcare teams. Hopefully, this article provides insight and perspective to you, my future colleagues and the next great generation of internists.

Emily C. Haines
Osteopathic Representative, Council of Student Members
Des Moines University College of Osteopathic Medicine, 2008
E-mail: Emily.c.haines@dmu.edu

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My Kind of Medicine: Real Lives of Practicing Internists: Kevin Egly, MD

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As a boy, Dr. Kevin Egly learned how a skilled physician can make a positive impact on people’s lives. It was the 1970s and Kevin’s grandfather had been battling heart failure for years before finally agreeing to have open heart surgery. In those days, what doctors were able to do for heart patients was limited. His physicians gave him a prognosis of 10 years following the surgery, but he lived for 18 years instead. Experiencing the wonder of modern medicine at an early age instilled in Dr. Egly a conviction that great things actually could happen, especially if you were a doctor. “I thought it would be pretty cool if I could do something like that,” he says. Today, the 37-year-old internist from Illinois is doing just that. He is driven by a strong faith in himself and his peers. “Physicians are committed to the health of their patients,” he says, “and we will always do what is right, regardless of the obstacles.”

Drs. Kevin and Angela Egly with Adam (6 years old), Matthew (4 years old), and Christopher (1 year old)Drs. Kevin and Angela Egly with Adam (6 years old), Matthew (4 years old), and Christopher (1 year old)

The Natural

As he became older, Dr. Egly’s wish to become a doctor was made more probable by an innate interest in the sciences. He had a natural proclivity for biology and chemistry. As time went on and more of his abilities emerged, his dream became more of a reality. In high school he breezed through science courses, acing exams and even winning an award or two along the way. At the University of Illinois, he was so adept at anatomy that he taught fellow pre-med students as a teacher’s assistant. In medical school, he organized mock practical exams for his fellow medical students.

His talents did not go unnoticed. While on rotation at the Loyola University Medical Center, Dr. Egly, then a senior resident, was called on by his attending to see a patient who had been examined but had yet to be diagnosed. Upon further examination of the woman, he noticed some physical examination findings that seemed to indicate a problem with the patient’s cranial nerves and further diagnostic tests were ordered. When the results came back, Dr. Egly was able to make the correct diagnosis: an early case of bacterial meningitis, which can result in brain damage or death if left untreated. “After that my supervisor said to me, ‘You are a doctor’s doctor.’ I didn’t really know what it meant, but it meant something to me that he said it.” As it turned out, he was a natural for the field of internal medicine. One of the often cited reasons for choosing internal medicine is the ability to diagnose complex medical conditions.

A Cool Head

Dr. Egly is full of real-life stories like that of the patient with meningitis. He recites them in a casual matter-of-fact tone, as if he were telling you about what he was planning on having for dinner. There is not much that really throws him. On one occasion, while working at Valley West Community Hospital in Sandwich, Illinois, he saw a patient who had come from the ER with an odd combination of presenting symptoms: a swollen face (from being hit) and a hypothermic temperature of 94 degrees. For no apparent reason, the woman began to slip into respiratory failure and had to be intubated. Things were not looking good. Then Dr. Egly got an idea. “We were having trouble clearing her oral secretions,” he said, “which led me to suspect that she had an early pneumonia compounded by an undiagnosed low functioning thyroid. Once I discovered this we were able to give her the correct treatment. The condition was corrected, she was rehabilitated and everything turned out fine, but only because we anticipated the thyroid dysfunction. If left untreated this condition carries an 80% chance of mortality.”

On yet another occasion, he diagnosed his twin brother, over the phone with a protein breakdown in the muscles (rhabdomyolysis) based on only two complaints: pain in the arms and urine “the color of Coca-cola.” Dr. Egly advised his brother, who was training heavily for a marathon, to go to the ER. Instead, his brother chose to visit a clinic and was given a different and much less serious diagnosis by a physician. Later on in the day his condition had not improved, at which point he did heed his brother’s advice and went to an ER. When Dr. Egly arrived the next day after flying out overnight to see him, his brother was in intensive care, undergoing treatment for rhabdomyolysis. “That was the most memorable diagnosis I’ve made, and it was over the phone,” he recalls.

Architect of His Own Destiny

Dr. Egly’s steady-as-you-go demeanor and unique aptitude would have made him a great surgeon, something he considered pursuing before he discovered internal medicine. “I just assumed that I would go into surgery since I was so good at anatomy, but my hands shook when I drank coffee. The surgeons didn’t like that,” he recalls. Once he got a glimpse of what being an internist would be like, he was hooked. “As a resident, I remember at the end of each rotation saying to myself, ‘Wow, I’d like to do that.’ I realized that I wanted to do all of it; I liked it all. With internal medicine, you can do it all.”

During his training, Dr. Egly saw something else that he liked a lot: Angela—a pretty blond with a sharp mind and green eyes who was a fellow medical student one year ahead of him in the program. Not one to be intimidated, he summoned his trademark confidence and asked her out. They began dating and ten years later they have three sons, ages six, four and one, and work side-by-side at a private practice they created together. He says setting up your own practice is not easy, but that running his own office means calling the shots, which is well worth the effort. “We designed our clinic to be very efficient,” he says. “We conduct patient care the way we think it should be done—one hour with every new patient and a half hour to 40 minutes with every follow up. The official name for such a practice is Ideal Micro Practice, or IMP for short. It requires efficiency in office procedure and coordinating patient care. We use an electronic medical record (EMR) system from eMDs and an online resource called www.Howsyourhealth.org. Running my own business means I’m the master of my own life. I enjoyed my days working for hospitals and a large specialty group, but having my own practice gives me a great quality of life.”

True to form, Dr. Egly is optimistic and undaunted about his future. “We need to take the next step in creating efficiencies that will help us make the transition to patient-centered coordinated care,” he says. “That means developing an electronic disease management program. If you can manage your checkbook online there’s no reason why we can’t come up with a way or a tool to manage your healthcare online. We haven’t developed that tool yet, but at some point we will. Or I’ll do it myself.”

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Internal Medicine Interest Group of the Month: University of California, San Francisco

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The Internal Medicine Interest Group (IMIG) at the University of California, San Francisco (UCSF) School of Medicine has received remarkable support from all facets of our community. Our students, faculty, administration and the American College of Physicians (ACP), both at the chapter and national level, have ensured our continued momentum and growth in advocating for issues concerning internal medicine, a particularly poignant mandate at a public institution such as UCSF. In transitioning leadership from our predecessors, Gina Choi ’08 and Genie Kim ’08, student leaders in the class of 2009 sought an open leadership structure whereby programmatic logistics were circulated equitably to ensure individual ownership in our IMIG. As a result, twelve students organized an agenda of innovative programs to address our goals of networking, education, and service.

ACP catalyzed the year by funding an evening event, co-sponsored by the Geriatrics Interest Group (GIG), to meet with faculty over dinner. Dr. Cindy Lai, one of our faculty advisors, graciously hosted the dinner at her home and assisted in recruitment of various internists and subspecialists to ensure a low 3:1 student to faculty ratio. Partnering with GIG further ensured a diverse assemblage of faculty and representation of fields while also lessening the financial burden of a catered event. Forty-five students and faculty participated in the dinner, which proved to be a unique and successful opportunity to dialogue with faculty and meet potential mentors in a casual setting.

UCSF’s IMIG also hosted a year-long series of five noon conferences to explore subspecialty opportunities in internal medicine. The fully integrated, organ and case-based curriculum at UCSF directed scheduling of topics, whereby presentations reflected the current course material of the first and second-year students. The events were thus aligned with the existing structure of the curriculum, which synergized our ability to pique student interest and maintain strong attendance as a natural extension of our coursework. Our Faculty advisor, Dr. Karen Hauer, regarded the events as important venues to “hear about the clinical practice, training, career options and lifestyles in different internal medicine practices.” One to three faculty members participated at a time, often presenting a case to stimulate discussion or to segue into discussions of personal career paths and practical issues of training and lifestyle. These subjects are rarely approached in the formal curriculum. Through these noon activities, we effectively engaged students’ interest within the greater context of adult medicine.

A shadowing program allowed first and second-year students to join a medicine team for morning rounds and noon conference. This program gave them the opportunity to observe internists and a preview of the third and fourth-year clinical experiences. To appeal to an even wider audience, Adam Schickedanz ‘09 and Judy Kim ‘09 coordinated a pair of unique and well-received physical exam workshops as part of National Primary Care Week. Each workshop, consisting of roughly a dozen stations, was run by second-year medical students who posed as “standardized” patients. This unique peer setting created a safe and comfortable environment for students to receive constructive feedback on their physical exam performance from their more-experienced colleagues. Mr. Schickedanz and Ms. Kim recall that the sessions “fostered one of the basic pillars of the art of medicine” where professional conduct, effective and efficient technique, and the ability to communicate findings in both medical and lay terms were key points critiqued during the sessions. Moreover, faculty and fourth-year medical students were available to clarify concepts and offer advice. The workshops were strategically offered just prior to the first-year physical exam practical evaluations, providing a timely opportunity for students to refine their skills.

Dr. Calvin Chou, Co-director of the Foundations of Patient Care (FPC) course, commented that, “The student-organized workshop accomplished numerous goals that a traditional course cannot. Second-year students, with their recent experience of learning the complete physical exam, are much more able to assuage first-year students’ anxieties. Feedback between the two ‘near-peer’ groups facilitates communication and lessens the power differential that first-year students can feel when working with faculty observers. Student organizers focused tremendous energy and enthusiasm into their leadership, and the rousing success of the program showed this.” These subjective accomplishments were apparent from the number of participants: over 80% of the first-year medical students and 45% of the second-year students volunteered for the workshops. Given this tremendous success, Mr. Schickedanz and Ms. Kim are working with the administration to possibly integrate the workshops as an adjunct to the FPC curriculum.

Our increased visibility on campus has allowed the UCSF IMIG to begin a dialogue with our region’s ACP Governor, Dr. Molly Cooke, regarding additional funding and greater coordination of our mutual interests. In the coming months, we hope to establish a formal relationship with the ACP California Chapter as well as contact the other California IMIGs for chapter-level idea and resource sharing. The coordinators of the UCSF IMIG would like to thank Drs. Hauer and Lai and Lisa Carella in the Office of Student Programs for their responsiveness and dedication to student enrichment. We would also like to thank the UCSF Department of Medicine and ACP for their generous funding.

Having recently transitioned leadership to the class of 2010, the IMIG at UCSF is well positioned to continue developing activities and programs to further the field of internal medicine while evolving to reflect and impact the ever-changing dynamics of our students and curriculum.

Brook Calton, Melissa Fitch, Judy Kim, Kenta Nakamura and Adam Schickedanz
IMIG Student Coordinators, Class of 2009
UCSF School of Medicine
E-mail: Kenta.Nakamura@ucsf.edu

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Winning Abstracts from the 2006 National Medical Student Poster Competition: Mitochondrial Injury and Non-alcoholic Steatohepatitis

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Author:
Debasish Sundi, Northwestern University, Feinberg School of Medicine, 2008

Introduction:
Non-alcoholic steatohepatitis (NASH) is a disease of the liver linked to obesity and diabetes. The main cellular features of NASH are steatosis, inflammation, and fibrosis. 30% of 1.6 million children that have fatty liver disease in the U.S. are thought to have NASH. The mechanism by which NASH evolves and progresses is unknown; this is a barrier to revealing pharmacologic targets that can prevent or treat NASH. The goal of my research is to confirm the presence reactive oxygen species (ROS) as an important cell signal in an in vivo model of NASH. An in vivo murine model of NASH is the Methionine- and Choline-Deficient (MCD) diet. The extent of oxidation within mitochondria is measured by aconitase activity, which decreases upon oxidation of its 4Fe-4S active site cluster. NADPH fluorescence at 340 nm is a proxy for aconitase activity. We hypothesize that in our model of NASH, increases in ROS cause aconitase activity to decrease.

Methods:
6-8 weeks old female A/J mice were divided into control and experimental groups. Control mice received a standard laboratory diet. Experimental mice received the MCD diet. Livers were excised and snap frozen in liquid nitrogen and stored at -80 C° until assay. 100 mg liver tissue per sample was homogenized with 50 μl protease inhibitor and 950 μl homogenization buffer (65 mM Tris HCl pH 7.5, 1.0 mM Sodium Citrate, 0.5 mM MgCl2). Each homogenate was centrifuged at 800g for 10 minutes at 4 C° to pellet out the crude nuclear fraction. The supernatant was centrifuged at 15000g for 15 minutes at 4 C° to form a mitochondrial pellet, which was subsequently re-suspended with 500 μl homogenization buffer and sonicated on ice for 20 seconds, twice. Protein concentration was estimated using a modification of the standard Bradford method that uses a protein precipitation step that eliminates interference from lipids (Pande and Murthy 1994, Anal Biochem). Precipitation reagents were 80% ethanol, 250 mM CaCl2, and 500 mM K3PO4. 5 μg of mitochondrial protein was added in a test tube to 3.4 ml PBS, 200 μl 10 mM Sodium Citrate, 200 μl 1.0 mM NADP, and 200 μl 1.0 U/ml Isocitrate Dehydrogenase. NADPH production was read at 340 nm on a Sequoia-Turner 112 fluorometer.

For fluorescence microscopy, AML-12 hepatocytes grown to 70% confluence were made quiescent with serum free medium for 24 hours. Cells were exposed to MCD or control media for 10 min to 3 hours. ROS was evaluated by co-staining with fluorescent dyes, dihydroethidium (DHE, a ROS specific vital dye) and DAPI for double-stranded DNA. A cell permeable superoxide scavenger, Mn (III) tetrakis (4-benzoic acid) porphyrin chloride was used as a negative control. Pre-incubation for 22 hours with 3-Nitropropionic acid, a known mitochondrial toxin, was used as a positive ROS control.

Results:
An assay for aconitase activity was successfully developed and implemented. There are not distinct differences in aconitase activity among control and MCD samples at time points ranging from 2 to 21 days. However, DHE staining showed marked ROS activity in the cytoplasm of MCD-treated AML-12 hepatocytes peaking at 30 minutes, compared to control cultures.

Conclusion:
The in vivo aconitase assay did not demonstrate increased ROS in livers of mice fed a NASH-inducing MCD diet. However, an in vitro fluorescence microscopy assay demonstrates that MCD-medium is associated with increased ROS in murine hepatocytes.

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Selected Career Paths: Highlights about Careers in Internal Medicine: Hospital Medicine/Hospitalists

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The Discipline

The national association for hospitalists, Society of Hospital Medicine, defines hospitalists as “physicians whose primary professional focus is the general medical care of hospitalized patients.” 95% of hospitalists are trained in internal medicine and 5% in family medicine.

Procedures/Specialized Skills

The scope of hospitalist practice may include the care of general medical patients and co-management of surgical cases, palliative care, and intensive care unit (ICU) patients. Common procedures are arthrocentesis, lumbar puncture, paracentesis, thoracentesis, and vascular access.

Training

Although fellowship training is currently not required of hospitalists, more than 20 fellowship programs exist. They are typically one to two years in length and offer additional certifications in public health, quality improvement and clinical research.

Certification

No certification currently exists for hospitalists.

Training Positions

Fewer than 50 hospital medicine fellowships are available annually.

Practice

In hospitalist practice, 34% are employed by hospitals, 20% employed by academic institutions, 20% by management companies, 20% by medical groups and the remainder in hybrid arrangements.

Major Professional Societies

American College of Physicians
Society of Hospital Medicine

Major Publications

ACP Hospitalist
Annals of Internal Medicine
The Hospitalist
Journal of General Internal Medicine
Journal of Hospital Medicine
Today’s Hospitalist

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Advocacy Briefs: Kennedy Introduces Student Loan Oversight Bill

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On February 1, Senator Edward Kennedy (D-Massachusetts) and Senator Richard Durbin (D-Illinois), introduced the “Student Loan Sunshine Act” (S. 486) intended to “protect students and parents from exploitation by private lenders and lenders who offer gifts to colleges as a way to secure loan business.” The Sunshine Act requires full disclosure and explanation of special arrangements that lenders and colleges have to offer loan products at the college; bans lenders from offering gifts valued over $10 to college employees; requires preferred lender lists to have at least three non-affiliated lenders; and encourages borrowers to participate in the government’s loan programs before taking out private loans.

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Did You Know ACP Medical Student Members Can Attend Internal Medicine 2007 with No Registration Fee?

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Medical students are warmly welcomed each year at ACP’s national conference and 2007 will be no exception. The conference provides an opportunity to meet like-minded students and physicians, to learn more about internal medicine, and to experience the camaraderie and cutting-edge developments in the field. Read on to discover why you should attend Internal Medicine 2007 (formerly Annual Session) held April 19-21 in San Diego, California!

Scientific Program Sessions

Physicians from all over the country are drawn to the meeting for its 250 educational sessions. Workshops range from general internal medicine to its many subspecialties and include topics as varied as Arthrocentesis and Soft Tissue Injections; Best Drug or Best Advertised Drug?; Business of Medicine 101; Disaster Preparedness; Healthcare for the Homeless; HIV Update; Mastering Cardiac Murmurs; and Grand Rounds: The Professor in Action. Students are welcome to attend all sessions.

Workshops Designed for Medical Students by Medical Students

The Council of Student Members develops content for the following sessions held especially for Medical Student Members: Brush Up for the Boards; Ethics and Professionalism for Medical Students; Getting Through the Match; and Stump the Professor.

Clinical Skills Review Course

Students can prepare for the USMLE Step 2 Clinical Skills Examination by participating in the Waxman Learning Center’s Clinical Skills Practice Session. This session has four stations that simulate the experience of the USMLE Step 2 Clinical Skills Exam. Standardized patients will present you with common problems and provide expert feedback on your history and physical examination skills, communication skills, and written note. A checklist score will be generated and shared with you in addition to other verbal feedback on your overall performance. You will be provided with a written evaluation summarizing the feedback as well as highlighting areas of strengths and weaknesses. Two students will be paired together for the four station workshop, allowing each student two "hands-on" experiences and two observation experiences.

Medical Student Abstract Competition Winners and Poster Finalist Competition

The top ten winners of the 2007 Medical Student Abstract Competition will present oral abstracts of their research, community initiatives, and clinical cases. A group of poster finalists will display their work in the Medical Students-Associates Poster Area and compete for additional prizes.

Medical Student Mentoring Breakfast

The Medical Student Mentoring Breakfast is a 90 minute session where students can meet with internists in a casual setting. Invited mentors include physicians – both general internists and subspecialists – practicing or teaching in a variety of settings and of a broad range of ages, backgrounds, and interests. Bring your questions!

Third Annual Internal Medicine Residency Fair

Representatives from internal medicine residency programs across the country will be on hand to discuss the unique aspects of their programs with students.

Medical Students, Associates, and Young Physicians Recognition Reception

All medical students are invited to a wine and cheese reception on Saturday evening, where winners of the ACP Associate and Medical Student Poster Competitions in addition to the winner of the 2007 Doctor’s Dilemma™ Championship are honored.

Medical Students, Associates, and Young Physicians Hospitality Room

The hospitality room is open each day for students to come together for coffee, snacks, socializing, and relaxing. Books containing the top research abstracts will also be available in the hospitality room.

San Diego

Take some time in the evenings or in your free time to enjoy the spring weather in one of the country’s most beautiful cities!

ACP Medical Student Members attend Internal Medicine 2007 free! Nonmember medical students pay a $99 registration fee. To register for the conference, visit here. See you there!

Lucy Goddard
CSM Representative, New England Region
Yale School of Medicine, 2007
e-mail: lucy.goddard@yale.edu

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Students Needed to Work at Internal Medicine 2007

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The College needs medical students with basic to intermediate computing skills to help in our medical informatics workshops. We also need 2 medical students to assist in the central venous line placement workshop in the Herbert S. Waxman Learning Center. The students assisting in the central venous line placement workshop will be required to wear a surgical scrub shirt over their regular clothes, lie down, and be comfortable with participants using a handheld ultrasound over their neck and collarbone area. Students will be paid a small honorarium ($100 per half-day, $200 for a full day). If you are attending Internal Medicine 2007 and would like to help, please contact Lisa Rockey at (800) 523-1546 ext. 2588 or lrockey@mail.acponline.org.

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MKSAP for Students 3 Question 1

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A 63-year-old woman is evaluated because of a 6-kg (14-lb) unexplained weight loss over 8 months. She has a history of Graves' disease, mild osteoarthritis, and osteoporosis. Her medications include alendronate and calcium supplements. She states that she has had trouble concentrating at work and feels run down. She sleeps poorly, has a poor appetite, and has stopped walking for exercise. She does not use alcohol or tobacco. Within the last 8 months, she has had a normal pelvic examination with a Pap smear, a negative mammogram, a negative stool test for occult blood, and a negative sigmoidoscopy. Physical examination is unremarkable. The hematocrit is 37%, serum thyroid-stimulating hormone concentration is 1.1 µU/mL, and serum electrolytes, creatinine, and liver tests are normal.

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

( A ) Upper endoscopy
( B ) Abdominal computed tomography scan
( C ) Megestrol acetate therapy
( D ) Mirtazapine (antidepressant) therapy
( E ) Propylthiouracil therapy

MKSAP for Students 3 Question 2

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A 76-year-old retired accountant is evaluated because of memory difficulty of 1 year's duration. He has problems recalling names and is forgetful about current events and things he has recently heard. He continues to drive, has not had accidents or gotten lost, and continues to handle the household finances. He also continues his usual hobbies, which include playing cards and golfing, and denies feelings of depression. He has atrial fibrillation that is treated with diltiazem and warfarin.

Physical examination is remarkable for a Mini-Mental State Examination score of 27 out of 30 (he missed which day of the week it was by one day, and could recall only 1 of 3 items on short-term memory testing). There are no focal neurologic findings. Complete blood count and metabolic panel are normal, as are the serum vitamin B12 level and serum thyroid-stimulating hormone level. A noncontrast computed tomography scan of the head shows only mild periventricular white matter disease.

Which of the following is the most likely diagnosis?

( A ) Alzheimer's disease
( B ) Drug-induced memory problems
( C ) Impaired memory due to subtle hypothyroidism
( D ) Mild cognitive impairment
( E ) Multi-infarct dementia

MKSAP Answer 1

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Answer: D

Educational Objective: Recognize that major depression is a common cause of unexplained weight loss.

The patient has unexplained weight loss, with symptoms typical of major depression: fatigue, difficulty concentrating, and sleep disturbance. Mirtazapine is a newer antidepressant that is sedating. Weight gain is common with this medication.

Patients with depression may not realize that they are eating less, and may report weight loss as “unexplained.” In patients with weight loss, endoscopy of the upper and lower gastrointestinal tracts and imaging beyond a chest radiograph are unlikely to disclose a cause for the weight loss, in the absence of specific symptoms or laboratory abnormalities. Megestrol acetate is a synthetic progestin that is occasionally used as an appetite stimulant in cancer patients with cachexia. Treatment with megestrol acetate does not address the cause of the patient's problem. The patient's serum thyroid-stimulating hormone concentration is normal, and does not suggest a relapse of her Graves' disease and the need for propylthiouracil.

References

Fisfalen ME, Hsiung RC. Glucose dysregulation and mirtazapine-induced weight gain. Am J Psychiatry. 2003;160:797. PMID: 12668379

MKSAP Answer 2

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Answer: D

Educational Objective: Diagnose mild cognitive impairment.

The diagnosis of dementia is based on the presence of chronic memory impairment and impairment of other aspects of intellect that are sufficiently severe to affect social or occupational functioning. This patient's symptoms are most consistent with isolated memory problems and do not meet the criteria for a diagnosis of dementia because his deficits are limited to one area of cognitive function (memory) and there is no history suggesting that his impairments are sufficient to interfere with his usual activities. Although his current diagnosis is most appropriately referred to as mild cognitive impairment (MCI), this may represent the earliest stages of a dementing illness, with studies suggesting that patients with MCI have a high risk of progressing to dementia, with an annual conversion rate of 10% to 15%.

Multi-infarct dementia and Alzheimer's dementia are not appropriate diagnoses because the patient does not meet the criteria for having dementia. Furthermore, mild to moderate white matter disease is frequently noted on computed tomography scans of the head, and this finding alone cannot establish a diagnosis of vascular dementia. Hypothyroidism is not implicated because the patient's thyroid-stimulating hormone level is normal. Finally, although drugs are a key factor that need to be considered as potential causes of cognitive impairment, the history does not indicate recent medication changes and none of his medications have been implicated as directly affecting cognition.

References

Petersen RC, Doody R, Kurz A, Mohs RC, Morris JC, Rabins PV, et al. Current concepts in mild cognitive impairment. Arch Neurol. 2001;58:1985-92. PMID: 11735772

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Internal Medicine Residency Program Fast Facts

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Program Name: Eastern Virginia Medical School
Location: Norfolk, Virginia
Hospital Type: University Affiliated Community Hospital
Program Size: 16 First Year Positions, 39 Positions Total
First Year Salary: $42,000
Web Site Address: www.evms.edu/education/gme/internal.html

Program Name: University of Washington
Location: Seattle, Washington
Hospital Type: University-based Hospital
Program Size: 74 First Year Positions, 174 Positions Total
First Year Salary: $42,000
Web Site Address: http://depts.washington.edu/medweb

Program Name: Akron General Medical Center
Location: Akron, Ohio
Hospital Type: University Affiliated Community Hospital
Program Size: 12 First Year Positions, 28 Positions Total
First Year Salary: $44,000
Web Site Address: http://www.akrongeneral.org

Program Name: New York Medical College at Westchester Medical Center
Location: Valhalla, New York
Hospital Type: University-based Hospital
Program Size: 28 First Year Positions, 56 Positions Total
First Year Salary: $51,000
Web Site Address: www.nymc.edu

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Announcing the New Internal Medicine Essentials for Clerkship Students 2007-2008 Textbook

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The new Internal Medicine Essentials for Clerkship Students 2007-2008 textbook is available. Created by the American College of Physicians and the Clerkship Directors in Internal Medicine, Internal Medicine Essentials is written by 68 authors who direct internal medicine clerkships around the country, who help design the internal medicine curriculum, and who are actively involved in teaching students during their internal medicine clerkships. This invaluable guide demonstrates to students how to care for patients, prepare for clinical rounds, and study for the end of rotation examination. Internal Medicine Essentials covers the common problems and disorders a student is expected to understand and likely to encounter. The printed content is enhanced with clinical photographs, tables, screening tools, and other instruments on the Internet here. This is a unique resource that provides medical students with the skills they need to enhance learning during the third-year internal medicine clerkship.

List Price: $49.95
ACP Student Member Price: $39.95
Product #: 330361030
ISBN: 1-930513-82-8

Order online

You can also call ACP Customer Service to order at 800-523-1546, extension 2600 or 215-351-2600 (M-F, 9 a.m.-5 p.m. ET).

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Students: Join ACP for Free

Benefits of Membership for Students: ACP's free Medical Student Membership includes benefits designed especially to meet students' needs.

Join Now: Sign-up today and begin enjoying the benefits of ACP Medical Student Membership.