June 2007 E-Newsletter

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

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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 June’s contest question will be included in the July 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 58-year-old woman is evaluated because of a 6-day history of dysphagia. She denies weight loss, odynophagia, heartburn, and regurgitation and has never been treated for gastroesophageal reflux disease. Hypertension and osteoporosis were diagnosed 6 months ago and are currently being treated with furosemide and alendronate.

Upper endoscopy reveals a stricture in the mid-esophagus. Biopsy specimens show only chronic inflammation. The stricture is dilated endoscopically.

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

( A ) Refer for surgical fundoplication
( B ) Refer for esophagectomy
( C ) Begin a prokinetic agent
( D ) Stop the furosemide
( E ) Stop the alendronate

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Answer for May Contest Question

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Click here to see May's question.

Answer to May Contest Question: D

The goals of therapy for type 2 diabetes include an ideal hemoglobin A1c level less than 6.5% to 7%. A change in the therapeutic regimen is therefore indicated. The United Kingdom Prospective Diabetes Study demonstrated the progressive nature of type 2 diabetes and secondary failure of both medical nutrition therapy and monotherapy with sulfonylureas. Furthermore, sulfonylurea therapy is frequently associated with weight gain, which worsens insulin resistance. Finally, the maximal effective dosing of sulfonylureas is less than the maximally approved dose. Glycemic control rarely improves with sulfonylurea dosing beyond approximately 50% of the approved maximum amount. Multiple studies have demonstrated the advantage of adding synergistic therapies rather than substituting therapies. The addition of metformin to a sulfonylurea is considerably more advantageous than replacing the sulfonylurea in the case of secondary sulfonylurea failure. The pathophysiology of type 2 diabetes suggests a benefit to the combination of an insulin secretagogue, such as glyburide, with an insulin sensitizer, such as metformin. Although the addition of pioglitazone, another insulin sensitizer, has been shown to be effective in decreasing the hemoglobin A1c level, it is associated with further weight gain. Addition of metformin to therapy with an insulin secretagogue appears to be more weight neutral and would thus have relative advantage in a patient with progressive weight gain.

References

American College of Endocrinology, American Association of Clinical Endocrinologists. ACE consensus statement on guidelines for glycemic control. Endocr Pract. 2002;8(Suppl 1):5-40. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2003;26: Suppl 1:S33-50. PMID: 12502618 United Kingdom Prospective Diabetes Study 24: a 6-year, randomized, controlled trial comparing sulfonylurea, insulin, and metformin therapy in patients with newly diagnosed type 2 diabetes that could not be controlled with diet therapy. United Kingdom Prospective Diabetes Study Group. Ann Intern Med. 1998;128:165-75. PMID: 9454524 Turner RC, Cull CA, Frighi V, Holman RR. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49). UK Prospective Diabetes Study (UKPDS) Group. JAMA. 1999;281:2005-12. PMID: 10359389 Inzucchi SE. Oral antihyperglycemic therapy for type 2 diabetes: scientific review. JAMA. 2002;287:360-72. PMID: 11790216 Lebovitz HE. Oral therapies for diabetic hyperglycemia. Oral therapies for diabetic hyperglycemia. Endocrinol Metab Clin North Am. 2001;30:909-33. PMID: 11727405

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Medical Student Perspectives: Welcome from the Chair of the Council of Student Members

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Greetings! As a Medical Student Member of the American College of Physicians (ACP), you have joined over 22,000 fellow medical 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.

These are exciting times to be involved in internal medicine. The future is bright with change on the horizon. Many physicians are working hard to implement new methods of delivering healthcare, more efficient models, and greater patient-centered care. Remarkable physicians, residents, students, and politicians have stepped forward and have proposed great changes to internal medicine and its subspecialties—working together to improve our system of care. The future of internal medicine is exciting and is evolving. The ACP is at the forefront of the wave of innovation and is calling on us to be a force. They value medical students and their creativity. Being involved at the national level, I am continually amazed at the ACP’s constant expressions of the priceless nature of medical students’ opinions and their involvement in the future of medicine.

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 from 11 regions, 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. Contact information for your regional CSM representative can be found 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, visit the IMIG Resource Guide.

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 third annual Internal Medicine Residency Fair at Internal Medicine 2007 in San Diego, California. Also at the annual meeting, students had the opportunity to attend workshops to help them prepare for their futures, including "Brush Up For the Boards," "Ethics and Professionalism for the Medical Student," "Getting Through the Match," and the very popular "Stump the Professor." 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, the highly-esteemed Annals of Internal Medicine and our newest and most valuable day-to-day resource, Internal Medicine Essentials for Clerkship Students. 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. Each May, the Council has the opportunity to join physicians and members of the United States Congress in Washington, D.C. 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, such as education, professionalism, public policy, and many others. 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 to succeed in your medical training and career. We are looking forward to an exciting year ahead!

Sincerely, Landon Dickson
Chair, Council of Student Members
University of Utah School of Medicine, 2008
Email: Landon.Dickson@hsc.utah.edu

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My Kind of Medicine: Real Lives of Practicing Internists: Brian Hertz, MD

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Family at its best is a haven—a place where we come from, a place we will always belong, and a place to which we can always return. For Dr. Brian Hertz, family means all of those things, but so much more. It meant practicing patient care before he even knew what it was, at the age of 14 when his little brother Kevin suffered from spinal bifida. It meant taking on his share of responsibility when his mother, an ER nurse, needed his help. It meant learning the delicate art of caring for the terminally ill. It meant learning the importance of family, what it means to lose someone you love, and how you need to be strong for others. It was a premature role for Dr. Hertz, but he accepted it gladly.

Dr. Hertz and his wife, Cathy, on the west coast of County Mayo in Ireland.

Dr. Hertz and his wife, Cathy, on the west coast of County Mayo in Ireland.


Spending those long days with his brother and his mother left him more than memories; it shaped his decision to pursue medicine and set the tone for his approach as a physician. “When Kevin was in the hospital I met a lot of the doctors and the students,” he recalls. “They spent time talking to me and would even play videogames with me. I always remembered that, it really resonated with me.” In the years following his brother’s passing, Dr. Hertz’s introduction to the medical field was further encouraged by the conversations he had with his mother about her work. He was intrigued by the stories she told him, and later during his fourth year of medical school she was the one who gave him the inspiration he needed to make his final decision. “I knew from my mom that ER work is really like shift work—you never really get to know the patients,” he says. “I chose internal medicine because you do get to know the patients and establish lasting relationships with them.”

Something Old, Something New

The major milestones of Dr. Hertz’s life—the big decisions, his choice of a career, his passions, his marriage—all hark back to something in his past, especially when it comes to his family. His decision to pursue a medical career was highly influenced by his mother and brother. His wife, like his mother, is also a nurse. At Hines VA Hospital he treats veterans—veterans like his father, godfather, and father-in-law. As an assistant professor, Dr. Hertz teaches medical students in the same program he attended himself at Loyola University; his bachelor’s degree was earned at Notre Dame, which is the same alma mater of his mentors.

He is well aware of the parallels and admits to finding comfort in them. “The fact that my advisors went to Notre Dame made me feel more comfortable,” he says. “My program director at Loyola was particularly welcoming and he taught me a lot. He was very intuitive in the lectures he gave and he was always very responsive to my questions.” But once he felt at home, he understood that it was time for him to grow. He says it was during his residency that he learned some of the most valuable lessons. “Residency really helped me improve my communication skills,” he says, “my mentors taught me the front-line aspect of the job—how to interview a patient and how to effectively communicate with many different kinds of people.” Residency also forced him to learn to work in a way which was unfamiliar to him. “Around that time I also improved my ability to work on a team. In the past, I would have tried to do all of the work myself and get it done as fast as I possibly could. But working with a team where I wasn’t the lead really taught me to step back. Through those experiences, I learned how to be a better leader.”

Beyond Borders

One of the more professionally rewarding experiences for Dr. Hertz has been his travels to San Lucas Toliman, Guatemala, with a program offered by Loyola University for students and physicians to treat patients in third-world countries. He went for the first time as a first-year medical student in 1999, then later in 2003 and 2005 as a physician liaison to students. Paradoxically, the thing Dr. Hertz loves most about his job can be at times the same thing which makes it difficult—caring.

“I had an idea of what it might be like, but when you immerse yourself in a culture you realize that they don’t have the resources we do,” he says. As a result, many conditions which are treatable if caught early-on go undiagnosed, such as breast cancer. “On one of my first trips there was an older woman who came to us with a large breast mass,” he remembers, “and we were pretty certain she had fairly advanced breast cancer. We advised her to try to reach a more urban center to get a biopsy, but in reality, I don’t know if she was able to do that. We were unable to follow up with her,” he says sadly.

Back in San Lucas in 2003, Dr. Hertz treated a young man in his twenties for a sexually transmitted disease. Because he lacked the appropriate resources to do a complete workup, the only thing Dr. Hertz could do was prescribe an antibiotic, refer him to the local urban hospital, and wish him the best. It reminded him of the encounter with the older woman with breast cancer, and it stayed in his mind for the next two years. In 2005, when he returned to Guatemala, he was determined to follow up with the young man. He made a house call, where the former patient told Dr. Hertz how much better he felt and how grateful he was to have been treated by him. “He was really very sick when we had seen him two years before,” says Dr. Hertz, “and then here he was, recovered and just so happy that we had come.”

It is quite obvious how deeply Dr. Hertz is invested in his job and with his patients. It is easy to see how his compassion for people translates into career satisfaction. “I love the field of internal medicine,” he says. “It can be challenging and difficult at times, but it is also a lot of fun. It is a remarkably rewarding career.”

The Tie that Binds

At the age of 31, Dr. Hertz has had his share of personal heartache. About a year ago, Dr. Hertz’s mother, the ER nurse who inspired him to become a doctor and who nursed his little brother through his illness, had to be hospitalized for an extensive and invasive surgery, the outcome of which would affect her daily living for the rest of her life. Once again Dr. Hertz found himself at the bedside of a family member. “One of the toughest things as a physician is caring for another health care professional, one of their family members or one of your own family members,” he says. He was older and wiser this time around, but the pain was all too familiar. “Seeing my mom on a breathing machine was difficult,” he says.

Sadness may not be a stranger to Dr. Hertz, but thankfully, neither is joy. Since last year, his mother has recovered from her surgery, and Dr. Hertz, along with his family, is focused on the road ahead. He and his wife, Cathy, are planning to have children someday, after she completes a clinical nurse specialist degree. Cathy is a close ally to Dr. Hertz—she worked alongside him in Guatemala, she has supported him through hardships, and she shares with him common goals and dreams. The two met in Loyola’s Medical Center, where Dr. Hertz was completing his medical school training and Cathy worked as a nurse in the cancer ward. Against a dangerous combination of warmth, dedication, determination, beautiful brown hair and a killer smile, Dr. Hertz was no match. Their first date was at a Mexican restaurant called Fernando’s. They talked and laughed over burritos, and found they had more in common that they thought. As it turns out, they grew up in neighboring towns.

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Internal Medicine Interest Group of the Month: University of Kentucky

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The Internal Medicine Interest Group (IMIG) at the University of Kentucky is a vibrant, growing organization within the College of Medicine that continues to be a favorite among students and faculty alike.

Much of the IMIG’s work lies in providing information about and promoting the profession of internal medicine and its subspecialties. To this end, monthly meetings offer an opportunity for students to learn from and connect with faculty, residents and fellows. Examples of meetings from the past two years include a discussion of academic medicine vs. private practice, and providing information about specialties such as nephrology, cardiology, and gastroenterology. In addition, new faces in the growing Division of Allergy and Immunology, as well as a representative from the exciting new rheumatology fellowship, have also used our IMIG as a venue to introduce some of the ways in which the Department of Medicine continues to grow.

The 2006-2007 academic year also saw the inception of the annual Medicine Student-Faculty Meet and Greet, providing a means for IMIG members to connect with physicians outside the formal boundaries of the attending/lecturer format. Along with the Family Medicine Interest Group, the University of Kentucky IMIG co-sponsors an annual Primary Care Residency Fair, where medical students are able to become acquainted with dozens of residency programs from throughout the region.

IMIG members are also valued contributors to Scut Monkey Day, a student-run program that aims to provide ascending third-year students with the lowdown on how to be a successful student in the clinical years. Chief among the day’s activities is providing tips on the internal medicine rotation, which is in many ways the foundation of the third-year curriculum.

Achievements in community service are anchored by the annual Toys for Tots drive, a college-wide program sponsored by the group, in which toys for various age groups are collected from donation points throughout campus. These toys are then distributed to families in need to enhance their ability to give their children holiday gifts. With the election of a new Chair of Community Service, we look forward to not only continuing current projects, but also introducing new projects in our attempt to better serve others.

With the election of officers who span the breadth of the College of Medicine, the University of Kentucky IMIG is anticipating continued development and excitement. Expansion of community service and the creation of new opportunities for members to engage in departmental activities and the ACP are only a few ways the group is looking forward to growing during the future.

Jarrod D. Frizzell
President, Internal Medicine Interest Group
University of Kentucky College of Medicine, 2008
Email: jarrod.frizzell@uky.edu

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Winning Abstracts from the 2007 Medical Student Abstract Competition: Heavy Metal Mayhem

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Author: Kendra M. Harris, Johns Hopkins University School of Medicine, 2008

Introduction: Lead poisoning causes significant morbidity in children and adults in the United States. Healthcare professionals must recognize its clinical presentations and identify potential sources of lead exposure.

Case Presentation: A 28-year-old Indian émigré presented with an acute exacerbation of abdominal pain that had begun 2 weeks previously. On admission, his review of systems included 6 weeks of postprandial diarrhea and 12 weeks of low libido and difficulty ejaculating. He denied weight loss, anorexia, headaches and paresthesias. He denied the use of prescription medications but had started taking 3 ayurvedic preparations for sexual dysfunction 4 weeks prior to admission. His occupational history included home demolition work in urban Baltimore over the past year. Physical examination showed tenderness in the left lower abdomen without rebound or guarding. Laboratory investigations revealed a total bilirubin of 3.4 mg/dl and a direct bilirubin of 0.4 mg/dl. His hematocrit was 36.2% with an MCV of 79 fl and a corrected reticulocyte count of 1.5%. Leukocyte and platelet counts were normal but a peripheral smear revealed basophilic stippling of red blood cells. His creatinine was 1.3 mg/dl and his urinalysis noted 1+ protein. His amylase, lipase, LDH, AST, ALT, and iron were normal and an abdominal/pelvic CT revealed no abnormalities. Given his abdominal pain, indirect hyperbilirubinemia, peripheral smear findings and occupational history, a lead level was sent and came back at 66 mcg/dl (normal = 0). Lead poisoning was diagnosed, and the patient began treatment with 2,3-dimercaptosuccinic acid. After completion of chelation therapy, the patient’s symptoms resolved. In follow-up, the patient’s ayurvedic preparations were obtained and analyzed for lead content. Lead was found in all 3 pills in varying concentrations (puspadhanwa ras = 1,000,000 mcg/gm, purnachandra ras = 219 mcg/gm and makardhwaj gutika = 13.6 mcg/gm).

Discussion: Lead poisoning can affect many organ systems and cause a multitude of symptoms and laboratory abnormalities. Although the use of lead-based paint was banned in 1978, it is still found in older homes and can cause significant lead exposure. This patient’s demolition work likely led to mild lead toxicity, causing the initial diarrhea and sexual dysfunction. The contaminated ayurvedics he took to treat this sexual dysfunction intensified his lead exposure, likely precipitating the abdominal pain which brought him to the hospital. Unregulated ayurvedic preparations are a newly identified lead source. Through such preparations, this patient ingested approximately 10.7 grams of lead in the 4 weeks prior to admission. Physicians need to be aware of the importance of taking nonprescription medication and occupational histories, and be familiar with the various causes and presentations of this heavy metal toxicity.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Critical Care Medicine

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The Discipline

Critical care medicine encompasses the diagnosis and treatment of a wide variety of clinical problems representing the extreme of human disease. Critically ill patients require intensive care by a coordinated team. The critical care specialist (intensivist) may be the primary provider of care or a consultant. The intensivist needs to be competent not only in a broad range of conditions common among critically ill patients but also with the technological procedures and devices used in the intensive care setting. The care of critically ill patients raises many complicated ethical and social issues, and the intensivist must be competent in areas such as end-of-life decisions, advance directives, estimating prognosis, and counseling of patients and their families.

Procedures

Important procedural skills for the critical care medicine specialist include advanced cardiac life support, arterial blood gas sampling and interpretation, bedside pulmonary function, mechanical ventilation, placement of arterial and central venous lines, insertion of temporary pacemaker, endotracheal intubation, and placement of pulmonary artery catheter.

Training (via Internal Medicine)

Training in critical care medicine is most commonly pursued as part of a combined 3-year subspecialty fellowship in pulmonary and critical care medicine, after which the trainee is eligible for subspecialty certification in both pulmonary medicine and critical care medicine. In addition, a physician interested in critical care medicine can pursue training by alternative routes besides linking critical care with pulmonary medicine training. Such alternative routes include: (1) a two-year accredited fellowship in critical care medicine after internal medicine residency; (2) two years of fellowship training in advanced general internal medicine (that include at least six months of critical care medicine) plus one year of accredited fellowship training in critical care medicine; or (3) two years of accredited fellowship training in a subspecialty of internal medicine (three years for cardiovascular disease or gastrointestinal disease) plus one year of accredited clinical fellowship training in critical care medicine.

Certification

The American Board of Internal Medicine offers certification in critical care medicine. Certificates of Added Qualifications are also awarded from the American Board of Surgery, American Board of Pediatrics, and the American Board of Anesthesiology.

Training Positions

As of August 2005, there were 31 “stand-alone” ACGME-accredited training programs in critical care medicine with 126 active positions. 30% of the trainees were female and 36% were US medical graduates. There are also approximately 130 programs that offer combined training in pulmonary medicine and critical care.

Practice

Approximately 48% of the graduates enter clinical practice in critical care medicine in the United States, and 20% enter academic medicine.

Major Professional Societies

Society of Critical Care Medicine
701 Lee Street, Suite 200
Des Plaines, IL 60016
Phone: 847 827-6869
www.sccm.org/sccm

Major Publications

Critical Care Medicine

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Advocacy Briefs: ACP Endorses High-Need Physician Workforce Act

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The American College of Physicians recently endorsed the bipartisan High-Need Physician Workforce Incentives Act of 2007. The six-part bill introduced on June 6 by Representative Michael C. Burgess, MD, and Representative Henry Cuellar of Texas focuses on incentives for generalist physicians (family practice, internal medicine, pediatrics, emergency medicine, general surgery, and OB/GYN) to work in high-need areas.

The bill includes a scholarship program for generalist physicians in high-need areas. Scholarship recipients would receive up to $30,000 a year for medical school and after completing residency, serve as generalist physicians at high-need facilities for one year for each year they received a scholarship. The bill also calls for a loan repayment program, which would offer repayment of up to $35,000 of the principal and interest of an individual’s educational loans for each year of service at a high-need facility. Information on other elements of the legislation can be found here.

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Did You Know You Have Access to ACP Journal Club Online?

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ACP Journal Club contains concise abstracts of the major findings and latest clinical research from more than 150 medical journals, plus brief commentary from leading clinical experts indicating each study’s strengths and limitations and the advisability of using these findings in daily practice. ACP Medical Student Members have free online access to ACP Journal Club after they register online.

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MKSAP for Students 3 Question 1

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A 56-year-old man who has a significant family history of premature coronary artery disease comes to the office for coronary risk evaluation. He is physically active, is not overweight, and does not smoke. His blood pressure is 138/80 mm Hg. The total serum cholesterol level is 262 mg/dL, the low-density lipoprotein (LDL) cholesterol level is 181 mg/dL, the HDL cholesterol level is 32 mg/dL, and the triglyceride level is 238 mg/dL. Liver function is normal. The fasting plasma glucose level is 110 mg/dL.

He is treated with simvastatin, 40 mg/d. A lipid profile obtained 8 weeks later shows a total serum cholesterol level of 211 mg/dL, LDL cholesterol level of 128 mg/dL, HDL cholesterol level of 29 mg/dL, and triglyceride level of 210 mg/dL. His liver function remains normal.

Which of the following is the most appropriate next therapeutic step?

( A ) Add gemfibrozil
( B ) Add niacin
( C ) Increase the dosage of simvastatin
( D ) Continue the current therapy

MKSAP for Students 3 Question 2

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A 67-year-old woman is admitted to the emergency department because of sudden onset of chest pain and rapid pulse. She has no history of similar occurrences. Physical examination reveals a pale, diaphoretic woman in moderate respiratory distress. Blood pressure is palpable at 75 mm Hg systolic, and the pulse rate is 160/min. The lungs show bibasilar crackles. There is jugular venous distention, and heart sounds are distant, with a variable S1. A 12-lead electrocardiogram shows atrial fibrillation with a rapid ventricular response.

What is the most appropriate immediate therapy?

( A ) Digoxin, 0.50 mg, intravenously
( B ) Diltiazem, 20 mg, intravenously
( C ) Direct-current cardioversion
( D ) Rapid infusion of 250 mL normal saline

MKSAP Answer 1

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Answer: B

Educational Objective: Identify the optimal therapeutic approach for a patient who has a low high-density lipoprotein cholesterol level in the absence of elevated total and low-density lipoprotein cholesterol levels.

The patient's low-density lipoprotein level has reached the target goal of less than 130 mg/dL on simvastatin, but the low high-density lipoprotein (HDL) cholesterol level and high triglyceride level are both targets for additional therapy. Increasing the statin dosage might lower the triglyceride level further, but would have little effect on the HDL cholesterol level. On average, statins increase HDL cholesterol by only 5% to 7%. Both niacin and fibrates elevate the HDL cholesterol level and lower the triglyceride level. Thus, combination lipid-modifying therapy is required. Niacin–statin combination therapy is safer than a fibrate–statin combination. Slow up-titration of the niacin dosage is required, with a target goal of 1500 to 2000 mg/d, as tolerated.

References

Xydakis AM, Ballantyne CM. Combination therapy for combined dyslipidemia. Am J Cardiol. 2002;90:21K-29K. PMID: 12467937

MKSAP Answer 2

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Answer: C

Educational Objective: Manage acute atrial fibrillation associated with hemodynamic compromise.

The appropriate treatment in this hypotensive patient with evidence of pulmonary edema is prompt direct-current cardioversion. The risk of embolic events is outweighed by the benefit of rapid cardioversion. Normal saline should not be administered in the presence of pulmonary crackles, which suggest heart failure. Diltiazem is likely to worsen the hypotension. Digoxin will not act rapidly enough to slow the heart rhythm as the sole agent administered.

References

Fuster V, Ryden LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation): developed in Collaboration With the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol. 2001;38:1231-66. PMID: 11583910

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Internal Medicine Residency Program Fast Facts

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Program Name: Medical College of Georgia Program
Location: Atlanta, Georgia
Hospital Type: University-based Hospital
Program Size: 25 First Year Positions, 55 Positions Total
First Year Salary: $42,000
Web Site Address: www.mcg.edu/Resident/intmed/

Program Name: University of Kansas Wichita Program
Location: Wichita, Kansas
Hospital Type: Community-based Hospital
Program Size: 16 First Year Positions, 36 Positions Total
First Year Salary: $41,000
Web Site Address: wichita.kumc.edu/im

Program Name: St. Mary’s Hospital and Medical Center Program
Location: San Francisco, California
Hospital Type: Community-based Hospital
Program Size: 19 First Year Positions, 37 Positions Total
First Year Salary: $45,000
Web Site Address: www.stmarysmed.org

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Student Members Receive a 30% Discount When Ordering MKSAP for Students 3

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MKSAP for Students 3 includes over 400 patient-centered self-assessment questions and their answers in print and on CD-ROM. Designed for medical students participating in their clerkship rotation, the questions help define and assess a student’s mastery of the core knowledge base requisite to internal medicine education in medical school. The questions reflect the daily management dilemmas faced by internal medicine physicians and when coupled with the answer critiques, provide a focused, concise review of important content.

New in MKSAP for Students 3:

  • All new questions and critiques
  • More topics and chapters
  • 12 electrocardiogram questions
  • 24 color figure dermatology questions

List Price: $44.50; Student Member Price: $30.00

To order MKSAP for Students 3 please visit this website

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