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July 2006 E-Newsletter

• Welcome from the Chair of the Council of Student Members
• Internal Medicine Interest Group of the Month: University of Puerto Rico
• Enroll in ACP's Key Contact Program
• Intensive Insulin Therapy Reduced Cardiovascular Disease in Type 1 Diabetes
• MKSAP Questions (1,2)
• MKSAP Answers (1,2)

Welcome from the Chair of the Council of Student Members

Greetings! As a Medical Student Member of the American College of Physicians (ACP), you have joined over 19,000 fellow students in the largest medical specialty organization in the United States. The ACP recognizes that the future of internal medicine lies in the strength of its student members. Accordingly, the College offers its Medical Student Members valuable benefits, essential educational tools, and opportunities for involvement in public policy and healthcare reform. I invite you to join your student colleagues, residents, and attending physicians as we work together to revitalize internal medicine.

The Council of Student Members (CSM) is comprised of 13 students, representing all ACP Medical Student Members. The CSM meets twice a year to discuss issues of particular importance to medical students. We welcome your input and feedback, as we aim to enrich the quality of your medical school experience. To find the contact information for your regional CSM representative, please visit online. Your comments will help guide our Council as we propose policy and plan events that will impact all of our members.

In the coming year, the Council will strive to uphold our mission to “promote excellence and professionalism in medical students,” in order to ensure that you have an extraordinary experience learning about the field of internal medicine. We keep this mission in mind as we plan events and coordinate activities related to education, public policy, and membership for students throughout the year.

On a regional level, each Council member works diligently to promote activities related to internal medicine and to gather ideas from local Internal Medicine Interest Groups (IMIGs). The ACP has launched a new IMIG Sponsorship Program, which provides funding and support for internal medicine club activities, as well as further financial incentives for increasing the number of ACP Medical Student Members over the course of the academic year. For more details about this program, see the IMIG Sponsorship Program brochure.

Our organization relies on a strong foundation of dedicated members; consequently, the Council invests significant time promoting ACP membership among students. A strong camaraderie among students ensures that we identify common goals and cooperatively accomplish the tasks we set out to achieve. Through initiatives such as the IMIG Sponsorship Program, we work to establish stronger bonds between the IMIGs at local schools, the regional ACP chapters, and the national ACP organization. We want to foster the exchange of ideas and expand activities for medical students in order to increase their interest in careers in internal medicine. We are distributing lapel pins to our members so they can proudly identify themselves as ACP Medical Student Members. These are just a few of the exciting plans on the CSM agenda for the coming year. Please contact us with your ideas to boost membership at your school.

The Council plans and develops tools to assist students as they progress through medical school. In April, we hosted the second annual Internal Medicine Residency Fair at the ACP Annual Session 2006 in Philadelphia. Also at Annual Session, students had the opportunity to attend workshops to help them prepare for their futures, including "Mastering the Match" and "Surviving Your Internship." Perhaps you have consulted some of ACP's educational and clinical resources in your coursework thus far. Resources include MKSAP (Medical Knowledge Self Assessment Programs) for Students 3 and the highly-esteemed Annals of Internal Medicine. We hope that students will come to rely on these academic tools during medical school and continue to use them throughout their careers.

The CSM takes an active role in proposing resolutions that advocate for medical students' interests on a national level. We work hard to ensure that the leadership of ACP understands the environment in which the contemporary medical student learns and enacts policy that fosters the development of superb physicians. The Council had the opportunity to join physicians and members of the United States Congress in Washington, D.C. this past May for ACP Leadership Day. Leadership Day is a special event during which students and physicians lobby for important changes to the future of healthcare in the United States.

The CSM is dedicated to a variety of issues in internal medicine ranging from professionalism to public policy. With a strong body of Medical Student Members and your active participation in our organization, we can work together to ensure that the ACP provides you with the tools you need to succeed in your medical training and career. We are looking forward to an exciting year ahead!

Sincerely, Jim Small
Chair, Council of Student Members
Emory University School of Medicine, 2007
jfsmall@emory.edu

Internal Medicine Interest Group of the Month: University of Puerto Rico

The Internal Medicine Interest Group at the University of Puerto Rico (UPR) School of Medicine, named the ACP Student Chapter of UPR, was started 4 years ago. Through the years we have relied on the direct mentorship of Adelaida Ortiz, MD, FACP. We have also received the support and collaboration of Carlos González Oppenheimer, MD, FACP, and William Rodríguez, MD, FACP, the Governor of the ACP Puerto Rico Chapter. The past year’s activities began with welcoming the new class of medicine students, introducing them to the benefits of being a member of both the ACP Puerto Rico Chapter and the national organization, and inviting them to participate in the ACP Student Chapter of UPR.

A new academic activity that was implemented this year was the educational workshop series. The first workshop, led by Hilton Franqui, MD, a PGY-2, was on the topic of EKGs. Dr. Franqui provided an interactive, step-by-step discussion on reading EKGs, and covered everything from the basics to the pathologies. This coming year we also plan to offer a radiology workshop, titled “Basic Radiology for the Internal Medicine Physician.” This workshop will focus on the essentials of chest x-rays, abdominal x-rays, and a CT scan of the head.

Another example of the educational activities our chapter supported was Medical Jeopardy, a tradition which takes place every year. The questions were created by Dr. Franqui. The students participated in groups composed of representatives of the four classes (MS-I to MS-IV). The group with the best score received gift certificates to buy review books for board exams. Attendance was outstanding and it was a very educational and fun activity. This coming year we plan to open the competition to other schools of medicine in Puerto Rico for the first time.

The ACP Student Chapter of UPR has also been involved in several community activities. The first activity was a health promotion clinic at Colegio San Gabriel in San Juan, a school for hearing impaired children. For this activity, some of our members were trained in the basics of sign language. It was a very pleasing and exciting experience to be able to obtain basic medical histories and help people in the clinic. We are also participating in a school-wide project aimed at offering essential medical attention in the Capetillo Community Center in Río Piedras. We have supported this project since it began two years ago by participating in the health promotion clinics, helping with history taking and physical exam, and by giving educational conferences on topics such as hypertension, hypercholesterolemia, obesity, and diabetes. Students talked to patients about these topics for 10 to 15 minutes while the patients waited to be evaluated for the different services. The material covered with patients was obtained from ACP Online. We have also participated in a similar health promotion clinic that took place at the Manuel A. Perez Community Center.

I am pleased to say that the ACP Student Chapter of UPR was successful this year due to the efforts of all of the student members and the physicians previously acknowledged. We plans to continue to be active during the upcoming years and to create new activities for our members in the future.

Arelis Febles Negrón, MS IV
President, ACP Student Chapter of UPR, 2005-2006
University of Puerto Rico School of Medicine

Enroll in ACP’s Key Contact Program

ACP’s continued success on Capitol Hill greatly depends upon year-round grassroots support from the College’s nearly 4,500 Key Contacts. Key Contacts communicate with their members of Congress on issues of importance to internists and their patients, and report the results back to ACP. To enroll as a Key Contact, ACP members are not required to have existing relationships with their members of Congress. ACP gives them the tools necessary to develop and maintain relationships. The program is open to all membership categories. Enroll now in the Key Contact Program.

Intensive Insulin Therapy Reduced Cardiovascular Disease in Type 1 Diabetes

ACP Journal Club. 2006 May-Jun;144:63.
Nathan DM, Cleary PA, Backlund JC, et al. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med. 2005;353:2643-53.

Question

In patients with type 1 diabetes, does long-term intensive insulin therapy (IIT) reduce cardiovascular disease (CVD) events?

Methods

Design: Long-term follow-up of patients in a randomized controlled trial (Diabetes Control and Complications Trial [DCCT] and Epidemiology of Diabetes Interventions and Complications [EDIC] study).

Allocation: {Concealed}†.*

Blinding: Blinded (outcome assessors {and laboratory technicians}†).*

Follow-up period: Mean 17 years.

Setting: 28 clinical centers in the United States and Canada.

Patients: 1441 patients 13 to 40 years of age with type 1 diabetes. Exclusion criteria were a history of CVD, hypertension (blood pressure > 140/90 mm Hg), or hypercholesterolemia (serum cholesterol level > 3 standard deviations above age- and sex-specific means).

Intervention: IIT ( > 3 insulin injections/d or an external insulin pump, with dose adjustment based on > 4 self-monitored glucose measurements/d, to reach a target blood glucose level 70 to 120 mg/dL [3.9 to 6.7 mmol/L] before meals and < 180 mg/dL [10.0 mmol/L] after meals and glycosylated hemoglobin [HbA_1c] level < 6.05%) (n = 711), or conventional therapy (1 or 2 insulin injections/d) (n = 730). At the end of DCCT (mean 6.5 y), patients in the conventional therapy group were offered IIT, and all diabetes care was subsequently carried out by the patients' own care providers.

Outcomes: Time to CVD events (nonfatal myocardial infarction [MI], stroke, CVD mortality, silent MI, angina, or revascularization by angioplasty or coronary artery bypass).

Patient follow-up: 93% (intention-to-treat analysis).

Main results

At mean 17 years (the end of EDIC), fewer patients in the IIT group had CVD events than did those in the conventional therapy group (Table). Previous allocation to IIT during the DCCT led to lower HbA_1c levels than conventional therapy (7.4% vs 9.1%, P < 0.01), but the 2 groups did not differ for HbA_1c level at the end of EDIC (7.9% vs 7.8%, P = 0.38).

Conclusion

In patients with type 1 diabetes, long-term intensive insulin therapy reduced cardiovascular disease events.

Sources of funding: National Institute of Diabetes and Digestive and Kidney Diseases and National Center for Research Resources.

For correspondence: Dr. D.M. Nathan, DCCT/EDIC Research Group, Bethesda, MD, USA. E-mail dnathan@partners.org.

*See Glossary.
†Information provided by author.

Intensive insulin therapy vs conventional therapy for type 1 diabetes‡

‡Cardiovascular disease (CVD) mortality, nonfatal myocardial infarction (MI), silent MI, revascularization, angina, and stroke. Abbreviations defined in Glossary; cumulative incidence, RRR, NNT, and CI provided by author.

§Number needed to treat intensively over a mean of 6.5 years to prevent 1 CVD event over a follow-up of 19.6 years.

Commentary

The DCCT showed that 6 years of IIT targeting normoglycemia markedly reduced diabetic retinopathy, nephropathy, and neuropathy in patients with type 1 diabetes. It was not designed to examine CVD events, although a trend toward reduced CVD events in the treatment group existed at the end of the active phase. The additional power provided by the passive follow-up of > 93% of the original DCCT cohort for a further 11 years, the relatively high CVD event rate of 0.42% per person-year in the control group (compared with 0.26% in the IIT group), and the preplanned analysis of the long-term CVD effect of the intervention have confirmed the initial trend. Thus, > 6 years of IIT reduces the long-term (17-y) risk for CVD events in patients with type 1 diabetes. Moreover, explanatory analyses suggest that the benefit of 6-year IIT was attributable to the lower HbA_1c level achieved, did not require the lower HbA_1c to be maintained during the 11-year passive follow-up phase, and persisted when a different definition of a CVD event was applied. Although the unblinded nature of the DCCT may have magnified the benefits of IIT if patients in the treatment group used more ancillary cardioprotective therapies than patients in the conventional therapy group, no evidence of such co-intervention was detected in the careful analyses that were reported. CV protection can be added to the list of benefits of IIT in patients with type 1 diabetes.

The high risk for severe hypoglycemia with IIT remains an obstacle to achieving optimal glycemic control. The challenges now are to identify new ways to safely and effectively implement this approach in patients with type 1 diabetes and to determine if the benefits also apply to patients with type 2 diabetes. Several clinical trials of glycemic control in patients with type 2 diabetes will be completed by 2009 (1).

Hertzel C. Gerstein, MD
McMaster University
Hamilton, Ontario, Canada

Reference

1. Buse JB, Rosenstock J. Prevention of cardiovascular outcomes in type 2 diabetes mellitus: trials on the horizon. Endocrinol Metab Clin North Am. 2005;34:221-35.

MKSAP Question 1

A 26-year-old woman comes to the office because of recurrent episodes of unusual behavior. She usually has a warning—a “weird” feeling in her stomach—prior to the episodes. Her husband has witnessed most of the events, and states that the patient suddenly freezes, looks around, smacks her lips, and moves her fingers repetitively. The episodes usually last between 30 seconds and 2 minutes. She has no recollection of the events after the warning. Afterward, the patient is confused and disoriented for as long as 10 minutes. The patient has had at least 10 episodes over the last 2 years.

Which of the following is the most likely diagnosis?

( A ) Absence seizures
( B ) Complex partial seizures
( C ) Migraine
( D ) Nonepileptic events (pseudoseizures)
( E ) Transient global amnesia

MKSAP Question 2

A 57-year-old man asks for help in preventing lung cancer. He is a current smoker and has smoked 1 pack per day for 30 years. He has tried smoking cessation counseling and nicotine gum, with no long-term success. He wants to know what measures he can take that have been shown to reduce the risk of lung cancer.

In addition to a smoking cessation program, which of the following is the best recommendation?

( A ) Annual spiral computed tomography scan of the chest
( B ) β-carotene supplements
( C ) Bupropion
( D ) Isotretinoin
( E ) Sputum cytology every 4 months

MKSAP Answer 1

Answer: B

Educational Objective: Recognize complex partial seizures of temporal lobe origin.

This is a typical description of a complex partial seizure of temporal lobe origin. The symptoms of complex partial seizures vary, but they are stereotypical for each patient. Patients may have a warning (aura) prior to the seizure. The most common warning is a rising epigastric sensation; other auras may include affective (such as fear), cognitive (such as déjà vu), and sensory symptoms (such as olfactory hallucinations). Complex partial seizures typically last less than 3 minutes. During that time, the patient appears awake, but loses contact with the environment and does not respond normally to instructions or questions. Patients usually stare and remain motionless, or engage in repetitive, semi-purposeful behavior (automatisms), such as gesturing, chewing, lip-smacking, repeating words or phrases, walking, running, or undressing. Patients do not recall these behaviors. After the seizure, the patient is confused or sleepy for minutes to hours.

Absence seizures occur primarily in children, are not preceded by an aura, and are not followed by postictal confusion. They last 5 to 10 seconds and occur primarily in clusters. Nonepileptic events (pseudoseizures) are characteristically variable (not stereotypical) in presentation and last longer. Migraine can be associated with neurologic symptoms, including confusion, but there is usually a history of headache or another obvious symptom (for example, visual phenomena). Transient global amnesia is a syndrome of acute memory loss of unknown etiology; it can last for minutes to hours. There is no alteration or loss of consciousness during transient global amnesia.

References

Mosewich RK, So EL. A clinical approach to the classification of seizures and epileptic syndromes. Mayo Clin Proc. 1996;71:405-14. PMID: 8637268

MKSAP Answer 2

Answer: C

Educational Objective: Treat a smoker with bupropion to decrease the risk of lung cancer.

The antidepressant bupropion has been shown to double the smoking cessation rate at 1 year in a placebo-controlled trial of cigarette smokers. Because smoking cessation is the only proven way to decrease smokers' risk of dying of lung cancer, prescribing bupropion is the best option for this patient.

Potential strategies to decrease the risk of lung cancer death in a patient who is having difficulty stopping smoking include more intensified smoking cessation efforts, medication to limit the cellular or DNA damage of the tobacco carcinogens, and screening to detect and cure small tumors. A number of studies have been undertaken.

In placebo-controlled randomized clinical trials of β-carotene to prevent lung cancer in smokers, the incidence and mortality rate of lung cancer were increased in the β-carotene study groups. Therefore, on the basis of current evidence, β-carotene supplementation is contraindicated for the prevention of lung cancer in smokers.

Although isotretinoin was shown to decrease the incidence of second primary tumors in patients treated for a primary squamous cell cancer of the head and neck, it did not improve the overall survival rate. In a study of patients who had been treated for early- stage non–small cell lung cancer, those randomized to receive isotretinoin did no better than those randomized to receive placebo. Furthermore, there was a trend toward increased lung cancer recurrence and lung cancer death in subjects who were smokers at study baseline.

In randomized trials, sputum cytology has not been shown to decrease the rate of death from lung cancer in smokers. In the Mayo Lung Project, monitoring of cigarette smokers by sputum cytology plus chest radiography every 4 months for 6 years was compared with usual care as a control arm. Although more surgically resectable cancers were detected in the screening arm, there was no decrease in the number of late-stage lung cancers. Furthermore, there was no decrease in lung cancer mortality in the screened arm.

Spiral computed tomography scans have been shown to detect early-stage lung cancers, but the false-positive rate is very high, and the effect on lung cancer mortality is unknown. Several randomized trials are in progress to test the net benefits and harms.

References

Jorenby DE, Leischow SJ, Nides MA, Rennard SI, Johnston JA, Hughes AR, et al. A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med. 1999;340:685-91. PMID: 10053177[PubMed]

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