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January 2006 E-Newsletter

• Focus on Careers in Internal Medicine: Cardiology/Electrophysiology
• 2006-2007 Council of Student Members (CSM) Call for Nominations
• Internal Medicine Interest Group of the Month: New Jersey Medical School
• Review: Tiotropium Reduces Exacerbations and Hospitalizations in COPD and Improves Quality of Life
• MKSAP Questions (1,2)
• MKSAP Answers (1,2)

Focus on Internal Medicine Careers: Cardiology/Electrophysiology

Following is an interview of Mark Haigney, MD, a practicing electrophysiologist and Associate Professor of Medicine and Pharmacology at the Uniformed Services University of the Health Sciences (USUHS). Dr. Haigney is also the Director the Cardiology. 2Lt. Javed Nasir, a fourth-year medical student at USUHS and the Military Liaison to the ACP Council of Student Members, conducted the interview.

IMpact: Thank you for taking the time for this interview. Many of our readers may be unfamiliar with the field of electrophysiology. Could you briefly describe the field of electrophysiology and the training necessary to become an electrophysiologist?

Dr. Haigney: An electrophysiologist is like an electrician for the heart. Electrophysiologists are specialists in abnormalities of the heart’s conduction system. To become an electrophysiologist, you must complete a three year internal medicine residency, a three to four year fellowship in cardiology, and an additional one to two years of training in electrophysiology. Electrophysiologists typically work at large medical centers and many spend the majority of their time working in an electrophysiology lab. Some of the more common procedures done in the lab include invasive testing of the electrical conduction in the heart, implantation of pacemakers and defibrillators, and ablation of cardiac tissue that may be causing arrhythmias.

IMpact: Electrophysiology seems like a highly technical and specialized career field. Do you still use your internal medicine training?

Dr. Haigney: Absolutely, I use my internal medicine training daily. Earlier today I evaluated a patient who was thought to have hypertrophic cardiomyopathy. However, after taking a careful history, I learned that this patient also had bilateral carpal tunnel syndrome and several other peripheral neuropathies. Since I have a strong foundation in internal medicine, I was able to consider options other than cardiac disease, and eventually found that this patient’s symptoms were attributable to amyloidosis.

IMpact: Where do you see the field of electrophysiology going in the next ten years?

Dr. Haigney: Currently, there is an acute shortage of trained electrophysiologists, partly due to the recent increases in the use of devices for patients with ischemic heart disease and heart failure. In the future, I hope this shortage will be ameliorated by decreases in atherosclerotic heart disease and possibly novel therapies for heart failure.

IMpact: Do you have any advice for medical students who may be interested in becoming a cardiologist and/or electrophysiologist?

Dr. Haigney: Both general cardiology and electrophysiology are terrific fields to work in. In addition to dealing with acute care, you also get to participate in longitudinal care. If a student is interested in these fields, I would highly recommend rotating through a cardiac care unit (CCU). Participating in a research project is another great way to learn about these fields. A research project allows to you work much closer with a staff cardiologist than a typical CCU rotation does. Also, as I mentioned earlier, it is very important to have a strong foundation in internal medicine, and students interested in cardiology should seek a strong internal medicine training program.

IMpact: What is the lifestyle like for a cardiologist?

Dr. Haigney: There was a time when cardiologists did not have much time for activities outside of the hospital. However, medicine has changed a lot and now most cardiologists I know have a good balance between work and other activities. Most have weekends off and typically take one or two months of vacation every year.

2006-2007 Council of Student Members (CSM) Call for Nominations

For the 2006-2007 Council year, seven seats will be open. The seats that will need to be filled are:

Midwest Region (includes Arizona, Colorado, Kansas, Minnesota, Missouri, Nebraska, Nevada, North Dakota, South Dakota, Utah, and Wisconsin)

New England Region (includes Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont)

North Central Region (includes Michigan, Ohio, and Pennsylvania)

Osteopathic Representative (includes all Osteopathic schools)

Pacific Region (includes Alaska, California, Hawaii, Idaho, Montana, Oregon, Washington, and Wyoming)

Southeastern Region (includes Florida, Georgia, North Carolina, South Carolina, and Tennessee)

Southwestern Region (includes Alabama, Arkansas, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas)

Candidates may be self-nominated. Nominations will be accepted from ACP Medical Student Members who are in their first, second, or third year of medical school. Council members serve one to three year terms, depending on where they are in their medical school careers.

Council members are required to attend three meetings each year and participate in several conference calls throughout the year. CSM representatives are reimbursed for their travel expenses for these meetings and other Council-related expenses.

Candidates should submit a statement of candidacy, curriculum vitae, and one letter of recommendation by February 1, 2006. The CSM will conduct the elections during March and all candidates will be notified of the results by mail by March 15, 2006. More details about the nominations process and a sample nomination can be found on the Students, Residents, and Fellows-in-Training Home Page on ACP Online. Each candidate will be reviewed with neutrality to gender, race, and ethnic background.

Candidates should send their materials to:

Patty Moore
Medical Student Coordinator
ACP
190 N. Independence Mall West
Philadelphia, PA 19106
Fax: (215) 351-2708
E-mail: pmoore@acponline.org

Internal Medicine Interest Group of the Month: New Jersey Medical School

Club Med, the internal medicine interest group at University of Medicine and Dentistry of New Jersey, New Jersey Medical School (NJMS), was established only two years ago but continues to be one of the most active and fastest-growing interest groups at NJMS. Over the past year, Club Med has established monthly meetings that seek to address the interests of both clinical and pre-clinical students via a variety of topics, such as “How to Beat the Match,” “What is an Internist?,” “Information on Internal Medicine Specialties,” and “How to Present to an Attending.” We also have one or two teaching rounds each month, called “ATMs: Attendings Teaching Medical Students,” where three or four students meet with an attending or chief resident to observe the more interesting cases that are currently on the floors. This provides students the opportunity to correlate their basic sciences with clinical presentation and to improve their physical diagnosis skills. This past October, Club Med hosted its Second Annual Internal Medicine Residency Fair, attracting residency programs from New Jersey, New York, Pennsylvania, and Connecticut. We are currently helping to plan a men’s health initiative with local and regional representatives from the American Medical Student Association to address the medical concerns of men in Newark. As a group, Club Med is always trying to improve itself by providing new programs that address the ever-changing needs of our student body. As such, Club Med is currently working with the Department of Medicine in order to create an elective that will familiarize students with the wards before their clinical rotations begin.

Tony Tarchichi
Council of Student Members Representative, Central Atlantic Region
UMDNJ, New Jersey Medical School, 2007

Review: Tiotropium Reduces Exacerbations and Hospitalizations in COPD and Improves Quality of Life

ACP Journal Club. 2005 Nov-Dec;143:59.
Barr RG, Bourbeau J, Camargo CA, Ram FS. Inhaled tiotropium for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005;(2):CD002876.

Question

In patients with stable chronic obstructive pulmonary disease (COPD), is tiotropium more effective than placebo or other bronchodilators for reducing risk for clinical endpoints?

Methods

Data sources: The Cochrane Airways Review Group Specialized Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE/Excerpta Medica, CINAHL, LILACS (to October 2004); hand-searching 20 respiratory journals, conference abstracts, and bibliographies of relevant studies; and contacting authors.

Study selection and assessment: Randomized controlled trials (RCTs) in any language that included patients > 35 years of age with known stable COPD without evidence of an exacerbation for 1 month before study entry, and compared tiotropium with placebo, ipratropium bromide, or long-acting β-agonists (salmeterol or formoterol) for > 1 month. Studies of patients with diseases other than COPD, previous asthma, cystic fibrosis, bronchiectasis, or other lung diseases were excluded. Study quality was assessed using Cochrane criteria for allocation concealment and the 5-point Jadad scale.

Outcomes: Exacerbations (respiratory symptoms lasting >3 d), hospitalizations for exacerbations, and all-cause mortality. Secondary outcomes included health-related quality of life assessed using the St. George's Respiratory Questionnaire (SGRQ) and the Transitional Dyspnea Index (TDI), change in FEV₁, change in FVC, and adverse events.

Main results

9 RCTs (n = 6584) met the selection criteria. Tiotropium was compared with placebo (8 RCTs), ipratropium (1 RCT), and salmeterol (1 RCT). Permissible co-therapies were β₂-agonists and inhaled corticosteroids. Allocation concealment was uncertain in 7 RCTs and adequate in 2 RCTs. 7 RCTs had a Jadad score of 4 out of 5 (range 3 to 5). Meta-analysis of 8 RCTs showed that tiotropium reduced exacerbations more than placebo (Table). Tiotropium was more effective than ipratropium in 1 RCT (relative risk [RR] 0.77, 95% CI 0.62 to 0.95). 3 pooled RCTs showed that tiotropium reduced hospitalizations more than placebo (Table). All-cause mortality did not differ between tiotropium and placebo (Table), ipratropium (1 RCT, RR 1.51, CI 0.41 to 5.50), or salmeterol (1 RCT, RR 0.17, CI 0.2 to 1.39). Tiotropium improved mean scores on the SGRQ (weighted mean difference [WMD] -3.27, CI -4.50 to -2.04) and the TDI (RR 1.53, CI 1.33 to 1.77); and increased FEV₁ (WMD 204 mL, CI 185 to 223) and FVC (WMD 387 mL, CI 343 to 431) more than placebo. Dry mouth was a frequent adverse effect in the tiotropium group (Table).

Conclusion

In patients with stable chronic obstructive pulmonary disease, tiotropium reduces exacerbations and hospitalizations, and improves health-related quality of life.

Sources of funding: No external funding.

For correspondence: Dr. R.G. Barr, Columbia-Presbyterian Medical Center, New York, NY, USA. E-mail rgb9@columbia.edu.

Tiotropium vs placebo for chronic obstructive pulmonary disease at mean 6.3 months*

*Abbreviations defined in Glossary; weighted event rates, RRR, RRI, NNT, NNH, and CI calculated from data in article using a fixed-effects model.

Commentary

The well-executed meta-analysis by Barr and colleagues documents compelling evidence for the efficacy of tiotropium in COPD. Tiotropium has shown beneficial effects for most outcomes that clinicians and patients with COPD consider important. Notable exceptions include mortality and decline in lung function over time. However, no other medications have yet been proven to alter these outcomes, either.

Evidence exists to support a preference for tiotropium over ipratropium, an older, short-acting inhaled anticholinergic that has been the mainstay of COPD therapy for years. Barr and colleagues identified 1 long-term RCT comparing the 2 drugs. This study had the highest methodological validity of any tiotropium study and showed benefits over ipratropium that were both clinically and statistically significant. The greater efficacy of tiotropium is biologically plausible because it has been shown to be more potent, selective, and longer-lasting than ipratropium (1). Furthermore, because ipratropium must be given 4 times/d, compliance with once-daily tiotropium is easier for patients. Finally, unlike tiotropium, no ipratropium studies have documented benefits for clinical outcomes, including exacerbations.

The major disadvantage of tiotropium is cost (up to 7 times more expensive than ipratropium). However, tiotropium is cost-effective in moderate-to-severe COPD (2). This would support the use of tiotropium over ipratropium in such patients.

Whether further benefits can be achieved with tiotropium in combination with long-acting ÿ-agonists and inhaled corticosteroids is the subject of a current, ongoing RCT. Other unanswered questions include whether a role exists for tiotropium in milder COPD and its role in inpatient management of COPD exacerbations.

Matthew B. Stanbrook, MD, PhD
University of Toronto
Toronto, Ontario, Canada

References

1. Barnes PJ. The pharmacological properties of tiotropium. Chest. 2000;117:63S-6S.

2. Oostenbrink JB, Rutten-van Mölken MP, Al MJ, Van Noord JA, Vincken W. One-year cost-effectiveness of tiotropium versus ipratropium to treat chronic obstructive pulmonary disease. Eur Respir J. 2004;23:241-9.

MKSAP Question 1

A 36-year-old woman is intubated and admitted to the medical intensive care unit because of respiratory depression following a barbiturate overdose.

Which one of the following will diminish her risk of developing a nosocomial infection?

( A ) Ventilator tube changes every 12 hours
( B ) Elevation of the head of the patient’s bed to 45 degrees
( C ) Intravenous ceftriaxone
( D ) Spraying of the oropharynx with a polymyxin B solution every 8 hours

MKSAP Question 2

A 16-year-old girl returns from a weekend campout with a local youth group complaining of abdominal cramping and malaise. She had two loose, bloody bowel movements. She has always been in good health and has no medical problems. On physical examination, she is in no acute distress. Her temperature is 37.2 ºC (99 ºF). Other vital signs are normal. Examination is normal except for hyperactive bowel sounds and diffuse, mild abdominal tenderness. The stool on the rectal examination is spotted with red blood.

Ingestion of which of the following is the most likely cause of this patient’s findings?

( A ) Fried chicken
( B ) Untreated water
( C ) Aspirin
( D ) Hamburgers
( E ) Precooked ham

MKSAP Answer 1

Answer: B

Educational Objective: Identify interventions that can reduce the incidence of nosocomial infection, particularly pneumonia, in mechanically ventilated patients.

Nosocomial pneumonia is a major cause of morbidity and mortality in mechanically ventilated patients. Various interventions have been suggested to reduce the frequency of this complication. Several studies suggest that in mechanically ventilated patients, the supine position and length of time in that position are risk factors for pulmonary aspiration. Elevation of the patient’s head to 45 degrees may reduce aspiration and thereby nosocomial pneumonia. There are no data to support the systemic administration of any antibiotic for prevention of nosocomial infection in the intensive care setting. Antibiotics should be reserved for treatment of an identified process and should be selected to cover the most likely pathogen(s) associated with the process. Selective digestive tract decontamination has been suggested as a means of decreasing bacterial translocation from the gut to other organ systems, but available data are conflicting and do not support widespread use of this approach. Likewise, the role of more limited decontamination (for example, of the oropharynx) is also undefined in the intensive care setting. Available information supports reducing the frequency of ventilator tubing manipulations and changes as a way of decreasing pneumonia. Bacteria colonize the condensate that pools in ventilator tubing, and even careful changing of the tubing potentially causes aspiration of these organisms. Changes less often than every 48 hours or no changes at all appear to be superior to more frequent changes.

References

• Torres A, Serra-Batlles J, Ros E, Piera C, Puig de la Bellacasa J, Cobos A, et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med. 1992;116:540-3. PMID: 1543307
• Gastinne H, Wolff M, Delatour F, Faurisson F, Chevret S. A controlled trial in intensive care units of selective decontamination of the digestive tract with nonabsorbable antibiotics. The French Study Group on Selective Decontamination of the Digestive Tract. N Engl J Med. 1992;326:594-9. PMID: 1734249
• Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001;334:665-71. PMID: 11228282

MKSAP Answer 2

Answer: D

Educational Objective: Recognize a typical case of foodborne infection caused by enterohemorrhagic Escherichia coli.

The clinical scenario is typical for infection caused by enterohemorrhagic Escherichia coli (EHEC). Bloody diarrhea, abdominal cramping, and absence of fever are common, and the disease tends to occur in previously healthy people who consumed underheated ground beef. Untreated water is an important source of Giardia lamblia infection, which can also present with abdominal pain and loose stools but not with bloody diarrhea. A small ingestion of aspirin is not likely to cause significant abdominal distress or frank blood in the stool. There is a risk for enteric infection associated with swimming or bathing, but none of the EHEC infections is commonly associated with water activities. Chicken is an infrequent vehicle for EHEC, although it is an important source of Campylobacter, Listeria, and Salmonella species.

References

• Su C, Brandt LJ. Escherichia coli O157:H7 infection in humans. Ann Intern Med. 1995;123:698-714. PMID: 7574226

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