2011 Annual Scientific Assembly Program Book by California Academy of Family Physicians

Professional Advancement | Personal Growth

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63rd Annual ScientiďŹ c Assembly May 14-15, 2011 Grand Hyatt Union Square San Francisco

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Professional Advancement | Personal Growth 63rd Annual Scientific Assembly • May 14-15, 2011 • Grand Hyatt Union Square • San Francisco, California

2011 Committee on Continuing Professional Development and Curriculum Development Teams: Geoffrey Leung, MD, Chair. David Bazzo, MD; Thomas Bent, MD; Christopher Flores, MD; Carol Havens, MD; Michael Potter, MD; Martin Quan, MD; Lee Ralph, MD; and Norma Jo Waxman, MD. The members of our CCPD, Board of Directors, Committees, and Staff declare no relevant financial relationships with corporations supporting this activity. The members of CAFP’s Committee on Professional Development work throughout the year with CAFP curriculum development teams to ensure that our continuing medical education activities are of the highest quality, providing clinical and practical relevance, and are presented free of promotional bias. If you have any comments or suggestions, they would be happy to hear from you. Our thanks to them for their commitment to the highest quality continuing medical education. The California Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.

Contents Hotel Map . . . . . . . . . . . . . . . . . . . . . . . . .

Going Green . . . . . . . . . . . . . . . . . . . . . . . . 4 Leadership Letter . . . . . . . . . . . . . . . . . . . . .

Complete Schedule of Events . . . . . . . . . . . . . . . 6 Meeting and Program Information . . . . . . . . . . . . 8 CAFP and CAFP Foundations, Industry, Corporate and Foundation Partners . . . . . . . . . 11 Award Winners . . . . . . . . . . . . . . . . . . . . . . 12 CAFP Foundation . . . . . . . . . . . . . . . . . . . . . 18 Family Physicians’ Political Action Committee . . . . . 19 Friends & Family Room – Assembly Exhibitors . . . . 21 Member Anniversaries . . . . . . . . . . . . . . . . . 22 Past Presidents . . . . . . . . . . . . . . . . . . . . . . 24 Board of Directors and Staff Directory . . . . . . . . . 25 CME Score Card . . . . . . . . . . . . . . . . . . . . . 27 San Francisco Recommended Restaurants . . . . . . . 29 San Francisco Map . . . . . . . . . . . . . . . . . . . . 30 Syllabus Saturday – Scheduled Sessions . . . . . . . . . . . . . . . 31 Sunday – Scheduled Sessions . . . . . . . . . . . . . . . 121

CAFP • 1520 Pacific Avenue • San Francisco, CA 94109 • Phone 415 345 8667 • E-mail cafp@familydocs.org • www.familydocs.org

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63rd CAFP Annual Scientific Assembly • San Francisco

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Grand Hyatt Theatre and Ballroom Levels Theatre Level

San Miguel

Potrero

Bultron

Rest Room

Conference Theatre

San Francisco B

Rest Room

Ballroom Level

Farallon Room Phones Rest Room

Dolores

Kitchen

West . . . . . . Plaza Ballroom . . . . . .

Plaza Foyer

East Merced A

Merced B

Rest Room

Room Assignments Registration

Plaza Foyer

YELLOW

Computer Camp/Silent Auction

Plaza Foyer

yellow

Friends and Family/CAFP Central

Dolores

Staff office

Merced A

Lecture Hall

Plaza Ballroom

New Physicians Reception and Battle of the Residents

Farallon

SAMs Groups

Conference Theater

BLUE

CME Leaders and Team Diabetes

Merced B

PINK

Meaningful Use – Workshops

Farallon

Professional Advancement | Personal Growth

RED PURPLE GREEN ORANGE

ORANGE

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Going Green CAFP is doing its best to make this meeting “Green.” This means more than just the environment – we’ve made a few changes we hope you’ll appreciate:

Our food and beverage selections have changed Our selections have been chosen to accommodate a menu lower in fat and calories, higher in grains, veggies, and fruits. We will not be providing sodas; no Cokes! You’ll receive your CAFP water bottle at CAFP Central; iced tea and water stations will be available throughout the meeting area – think lemon, lime, cucumber!

Our materials can be recycled and the Grand Hyatt is committed to “green.”  We’ve printed the program for your use, but hope if you decide you don’t need it that you’ll leave it in the recycle bin. Same for your morning newspaper, etc.  Badges can be recycled – leave them in the bin at the Registration desk – or take them with you for next year’s meeting!  We’ve got a ribbon bank this year – if you want a ribbon to show your Foundation or PAC support, grab one; if you want to go ribbonless, that’s OK too.  The evaluation form is online this year – easy to access, and you print out your CME certificate when you complete the evaluation.  The ASA Shopping bag can be thrown in your trunk and used at the grocery!  Among other green activities, the Grand Hyatt also: o Composts the food from its kitchen, has changed 95% of the lights to energy efficient compact fluorescent lights, and has upgraded thermostats for energy savings. o Recycles all paints and solvents through Safety Clean; batteries, ballasts and fluorescent bulbs through Earth Protection; and kitchen grease through Got Grease to make bio-diesel.

63rd CAFP Annual Scientific Assembly • San Francisco

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Leadership Letter May 14, 2011

Dear Colleague: It is our honor to welcome you to the 63rd Annual Scientific Assembly of the California Academy of Family Physicians, “Professional Advancement | Personal Growth.” Learning with one another and from one another is what family physicians do – just being together provides a sense of renewal from which we all benefit. This meeting is undoubtedly the premier family medicine CME program in our state – and one of the very best values for your CME dollar. You’ve made a wise and cost-effective decision to attend. We all need a break from the pressures of our every day practices and this is a great one. Your Academy has made every effort to bring to you high quality CME that meets your needs – especially as you may be facing the new Maintenance of Certification requirements for certification or re-certification by the American Board of Family Medicine. The program you are about to experience marries clinical CME content to the requirements set forth by the ABFM, based on a professional needs assessment and identification of key education gaps. It provides a mix of lectures, cases, audience response, learning assessments, hands-on workshops, patient videos and more. You can receive at least 14.25 evidence-based Prescribed Credits at extremely low cost, in one of California’s most beautiful cities, San Francisco. We’ve planned a full schedule for you – from lectures and panels, to SAMs groups and Meaningful Use workshops. We’ve invited some of your favorite faculty members, and are thrilled to introduce new presenters as well. We’ve included the perennial favorite “Battle of the Residents” which caps off a special day of diabetes training for Residents, and a New Family Physician Social. We’re very happy that you’ve chosen to attend and look forward to the opportunity to meet you during the next two days. Take advantage of this time to speak with your colleagues and share your experiences. Sincerely, Carol Havens, MD Jack Chou, MD CAFP President CAFP President-elect

Professional Advancement | Personal Growth

From the top: Jack Chou, MD Carol Havens, MD, Geoff Leung, MD

Geoff Leung, MD Chair, CAFP Committee on Continuing Professional Development

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Saturday • May 14, 2011 7:00 am-3:00 pm

Plaza Foyer

Registration

7:30 am-8:20 am

Merced B

CME Leaders Institute Breakfast Invitation Only

7:30 am-8:30 am

Farallon Room

Breakfast

7:30 am-3:00 pm

Dolores Room

Friends and Family Room / CAFP Central

8:30-9:00 am

Plaza Ballroom

General Opening: CAFP Incoming and Outgoing Presidents

9:00-10:00 am

Plaza Ballroom

Abraham Verghese, MD

The Importance of Bedside Medicine and Physical Examination in a Time of Advanced Technology

10:00-11:00 am

Shane Snowdon and Caitlin Ryan, PhD

Plaza Ballroom

LGBT Primary Care Health Priorities

11:00-11:30 am

Break

11:30-12:30 pm

Stephen Kraus, MD

Plaza Ballroom

Male Urinary Tract Symptoms: Overactive Bladder or Benign Prostatic Hyperplasia

12:30-1:45 pm

Lunch and Learn

Plaza Ballroom

Bo Greaves, MD; Chris Saddler, PA-C; and Lauren Lorenzo, APRN

Diabetes Care: A Team Approach -- How we can better help Mr. Sanchez

12:30-5:30 pm

SAMs Group #1

San Francisco A and Conference Theater

Cheri Olson, MD

Cerebrovascular Disease

Pre-Registration Required

1:45-2:45 pm

Carol Havens, MD

Plaza Ballroom

Prescription Drug Abuse/Dependence

2:00-3:30 pm

Team Diabetes / PI Teams Invitation Only

Merced B

2:45-3:15 pm

Break

3:15-4:15 pm

Thomas Bent, MD

Plaza Ballroom

4:15-5:30 pm

Plaza Ballroom

Breaking Down the Walls: Tackling the Barriers to Treating Depression Larry Culpepper, MD and Jeffrey Luther, MD

Circadian Rhythm Disorders: Asking the Right Questions

5:30-7:00 pm

New Physicians Social and Battle of the Residents

Farallon Room

All lectures are included in the registration price and do not require pre-registration.

63rd CAFP Annual Scientific Assembly • San Francisco

ASA | Schedule of Events Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð

Sunday • May 15, 2011 7:00 am-3:00 pm

Plaza Foyer

Registration

7:30 am-8:30 am

Farallon Room

Breakfast

7:30-12:45 pm

Dolores Room

Friends and Family Room / CAFP Central

8:30-9:00 am

Plaza Ballroom

CAFP Update / Sacramento Update

9:00-10:00 am

Plaza Ballroom

Christopher Flores, MD

Primary Prevention of Dementia: Evidence-Based Practical Recommendations

10:00-11:00 am

George Kent, MD

Plaza Ballroom

Hepatitis B Update

11:00-11:30 am

Break

11:30-12:30 pm

Marshall Kubota, MD

Plaza Ballroom

The Many Faces of MRSA: Recognizing and Treating the New At-Risk Populations

12:30-1:45 pm

Lunch and Learn

Plaza Ballroom

Lee Ralph, MD, Lauren Simon, MD and David Bazzo, MD

Head Trauma: From Concussions to Traumatic Brain Injuries

12:30-5:30 pm

San Francisco A and Conference Theater

SAMs Group #2 Michelle Quiogue, MD

Health Behaviors

Pre-Registration Required

1:45-2:30 pm

David Bazzo, MD and Company

Plaza Ballroom

Two Minutes, Two Slides, Two Questions

2:30 pm

Adjourn Main Stage

2:45-3:45 pm

Elise Singer, MD

Farallon Room

HIT: Meaningful Use 101: I Need to Register and Understand the Measures

4:00-5:00 pm

Elise Singer, MD

Farallon Room

HIT: Meaningful Use 201: Action Plan

All attendees receive complimentary admission to one of our Sunday workshops.

Professional Advancement | Personal Growth

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Meeting and Program Information CAFP’s 63rd Annual Scientific Assembly is a launching pad for several of CAFP’s new national initiatives – you get the information first! The clinical sessions will be presented in a variety of formats; each will be based on evidence-based practice recommendations and include case-based learning. Sessions will be presented with patient video cases, in a conversation style with two faculty members, or with an audience response system. Faculty members were selected from a pool of your favorite presenters. You won’t want to miss our Keynote address from Abraham Verghese, MD, author of Cutting for Stone. Clinical Sessions Our main stage program consists of 11 clinical sessions that will give you up-to-date information on research findings and treatment indications on a variety of diseases and important issues for your practice. All clinical sessions take place in the Plaza Ballroom. At the end of each session, five minutes will be provided for questions from the floor. Line up behind the microphone in the aisle nearest you. One question per person, please. SAMs Groups and Meaningful Use Workshops We’ve planned two SAMs group sessions – pre-registration was required. These sessions will be presented in the Conference Theater room; lunch and materials will be provided. CAFP will click “Submit” for you and the first portion of your SAMs will be complete. There will also be two HIT: Meaningful Use workshops on Sunday afternoon; they are divided for beginner and advanced, and require no preregistration or fee. Please join us in the Farallon Room. Continuing Medical Education Credit The California Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. CAFP takes responsibility for the content, quality, and scientific integrity of this CME activity. The CAFP designates this activity for 14.25 AMA PRA Category 1 Credits.™

This meeting has been reviewed and approved by the American Academy of Family Physicians for 14.25 Prescribed credits. AAFP Prescribed credit is accepted by the American Medical Association as equivalent to AMA PRA Category 1 Credit ™ toward the AMA Physician’s Recognition Award. When applying for the AMA PRA, Prescribed credit earned must be reported as Prescribed credit, not as Category 1. This ASA will be one of the first Transition-2-Practice pilot programs as well. Check the bottom of your evaluation form if you want to participate – and earn two more Prescribed credits! Special CME Reporting Form for CAFP Members You can quickly report your CME by going online to AAFP – www.aafp.org – and entering the credits directly – no middle person! We have also included a CME Scorecard for you to use to keep track of the sessions you’ve attended. Use it to report your CME to the AAFP and keep it for your records. CME Certificate and Meeting Evaluations You will receive an electronic CME Certificate for this meeting. To receive your CME certificate, you must complete your Annual Scientific Assembly evaluation form. There are two ways to complete your evaluation: 1. Click on the evaluation link on CAFP’s Web site: www. familydocs.org/professional-development/ASA.php, which can be accessed from our computer camp or when you get home. 2. Ask at the ASA registration desk for a paper evaluation form to complete and return to a CAFP staffer. The staffer will give you a certificate upon completion of the survey. The Computer Camp will also be open after the last session on Sunday; stop by and complete your Evaluation before you leave the meeting. Please take a few moments to fill out the meeting evaluation – this information is extremely important. Your opinions on topics and speakers provide the best source of information for planning the program of future Scientific Assemblies. Questions? Ask any CAFP staffer. Thank you!

63rd CAFP Annual Scientific Assembly • San Francisco

Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Registration Location: Plaza Foyer Hours: Friday, May 13 Saturday, May 14 Sunday, May 15

Emergency Preparedness 1:00 – 5:00 pm 7:30 am – 3:00 pm 7:30 am – 12:45 pm

CAFP Central – Member Services Location: Dolores Room Hours: Saturday, May 14 7:30 am – 3:00 pm Sunday, May 15 7:30 am – 12:45 pm Please stop by CAFP Central. CAFP staff members and leaders will be available during the morning sessions. We’re here to answer questions, provide information regarding member benefits, help you get more involved, and simply to say “Hi.” You can learn more about CAFP’s member services and upcoming events, find out about leadership opportunities, and peruse practice management resources developed by the Academy. Friends and Family Room Location: Dolores Room Hours: Saturday, May 14 Sunday, May 15

7:30 am – 3:00 pm 7:30 am – 12:45 pm

The Friends and Family Room will also be home to your refreshment breaks. Our friends provide practical solutions to you and your practice team – and they help support the CAFP meeting. We hope you’ll support them by stopping by, spending time discussing their services, and thanking them for their participation. We have new hours for the hall – we’ll be open 7:30 am-3:00 pm Saturday and 7:30 am-12:45 pm Sunday – giving you lots of time to visit friends and meet with CAFP staff and leaders. We’ll have beverage service available. For a complete list of participants, go to page 21. Computer Camp Location: Plaza Foyer Saturday, May 15 Sunday, May 16

7:30 am – 3:00 pm 7:30 am – 4:00 pm

This year we will be offering computer and printing access in our Computer Camp in the Plaza Foyer. You will be able to check e-mail, print syllabus materials and boarding passes, and complete your meeting evaluation. The computer lab is only available for attendees with name badges.

Professional Advancement | Personal Growth

For your general safety, picture identification is required for badge pickup and registration. Please wear your badge at all times within the hotel. Your badge will be required for admission to all CAFP sessions. Breakfasts, Lunches, Snacks and Beverages Continental breakfasts will be offered in the Farallon Room. Beverages and breaks will be available 9:00 am-12:30 pm in the Dolores Room. Lunches will be set in the Farallon – and we’ll have working/learning lunches. Every attendee and paid guest (tickets will be provided for paid guests) is invited for breakfasts and lunches. Guest breakfasts and lunches require an additional fee, which can be paid on site at the registration area. Breakfast Saturday and Sunday Farallon Room 7:30 am – 8:30 am Beverage Saturday and Sunday Dolores Room Service 9:00 am – 11:00 am Refreshment Breaks Dolores Room Saturday 11:00 – 11:30 am, 2:00 – 2:30 pm Sunday 11:00 – 11:30 am Lunch 12:30 – 1:45 pm Plaza Ballroom Saturday and Sunday New Physicians Social and Battle of the Residents We’ve merged the New Physicians Social with the Battle of the Residents this year – one big room, one big event! Join us at 5:30 pm, Saturday, in the Farallon Room. Jack Chou and Carol Havens – our outgoing and incoming Presidents – will kick off the 5th Annual Battle of the Residents. Teams representing CAFP family medicine residency programs will attempt to dethrone the 2010 Champs – Fresno-UCSF. Join us in the Farallon Room, Saturday afternoon to root for your favorite residency program and enjoy great “pre-game” treats. This event is open to all meeting attendees and guests. CAFP Foundation Silent Auction Don’t miss the CAFP Foundation’s 6th Annual Silent Auction! Bidding for auction items will be open Saturday and Sunday, May 14-15 with final bids placed at 12:45 pm on Sunday. Notice of winning bids will be made at 2:30 pm on Sunday as you leave the Lecture Hall. By bidding, you will help support the medical students on California’s campuses. A big CAFP-F thanks! 9

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CAFP Industry, Corporate and Foundation Partners This year’s exceptional value in CME is possible because of the corporations and foundations that generously provide grants and donations to help underwrite the costs of CAFP and CAFP Foundation educational programs and other efforts. There are absolutely NO strings attached to any of these support grants — control of ALL educational content and speaker selection remains entirely with CAFP. Educational grants are provided to ensure that important educational information is made available to family physicians. The companies listed below have provided support to family medicine and the ASA by making financial grants and/or donations to the meeting. CAFP wishes to acknowledge them for their support. Please thank your local representatives for recognizing the value of family medicine.

Educational Initiative

Corporate/Foundation Supporters

Cease Smoking Today initiative

Pfizer Medical Education Grants

Successful Strategies for Treating Patients with Overactive Bladder initiative

Pfizer Medical Education Grants, Astellas

PCMH Resource Center on www.familydocs.org

The Physicians Foundation

Redefining Hospice and Palliative Care for Primary Care Patients, live chapter series and online conversation

PriCara, a division of Johnson & Johnson

5th edition, Urine Drug Testing Monograph

Purdue Pharma, LLP

Diabetes Care: A Team Approach

Sanofi Aventis, Boehringer Ingleheim, Lilly, Merck

HIT Toolkit and Meaningful Use Activities

The Physicians Foundation

CME Leaders Institute

The Physicians Foundation

MRSA, live and online activities

Pfizer Medical Education Grants

Barriers to Treating Depression

Pfizer Medical Education Grants

Circadian Rhythms live activity and online pilot project

Cephalon

Medical Leadership Council for Cultural Proficiency

The California Endowment

Professional Advancement | Personal Growth

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2011 California Family Physician of the Year

Peter Broderick, MD The California Academy of Family Physicians presents this prestigious award to an individual who exhibits the finest qualities of family physicians and who goes above and beyond in service to patients and community. It is doubtful that his parents knew how significant his name “Peter William,” would be when they named their newborn 48 years ago. “Peter” of Greek origin, means “rock;” “William” means “protector.” There are no two better words to describe Dr. Peter W. Broderick – a family physician, residency program director, teacher, mentor, patient advocate, father and friend. As rock and protector, for the past six years Dr. Broderick has served as the Program Director of the Stanislaus County Family Medicine Residency Program. Within a month of accepting the position of Program Director, Dr. Broderick was faced with a crisis in the County that threatened the program’s existence. Little did he know then that this training by fire was his preparation for what would befall the residency program just four years later. In 2005, the County of Stanislaus, the institutional sponsor of the program, was facing a significant financial crisis within its health services agency. The common best thinking, including recommendations of consultants, was to close the program. Loss of this program – a residency program that focuses on service to the underserved residents of Stanislaus County – was clearly not an option. Dr. Broderick, with the support of the County and the community, began the process of saving the residency – by completely re-creating it. Throughout the complex process, Dr. Broderick was instrumental in reminding all involved to “warm the stone” and help build consensus among a diverse group of partners. He provided protection to the residency program and the principles and values of family medicine when some at the federal level recommended untenable “solutions.” He was consistently an advocate for the residents, program, and integrity of the specialty. He was the rock on the “bad days” when the options looked few and outcomes grim. And he did this, with the support of his faculty, residents, colleagues and friends, while continuing in his “real job” of physician, teacher, administrator, advocate, and community leader. Today, the Stanislaus Family Medicine

63rd CAFP Annual Scientific Assembly • San Francisco

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Residency program has been transformed as the new Valley Family Medicine Residency program. Dr. Broderick and his team were just awarded one of 11 prestigious grants from Health Resources and Services Administration to become one of the first Teaching Health Centers in the country! Dr. Broderick’s tenacity doesn’t end at his residency program. He is an advocate for his patients, encouraging them to take the next right step and facilitating their efforts, even if that means going to the store and purchasing medical supplies if they don’t have the resources. When Dr. Broderick noticed a dearth of GI physicians in his area, he went in pursuit of privileges at his local hospital and surgical centers to do colonoscopies to ensure access to this important procedure for patients in the community—even giving his fees to his mentors to ensure that he could complete enough procedures to obtain hospital privileges. Finally, Dr. Broderick is protector and rock of his community. He appears to seamlessly move between his many roles, always serving as a teacher and mentor in each. Administratively, he is the program director, the CEO of Valley Consortium for Medical Education, which is the sponsor for Valley Family Medicine. He is a practicing clinician, taking call in rotation with the rest of the faculty, and always is there to lend support to his residents. Dr. Broderick is also active in his community, involved in planning of the proposed UC Merced School of Medicine, health initiatives in the San Joaquin Valley, Board of Directors of Golden Valley Health Centers. In addition, he is President-elect of the Stanislaus Medical Society, a member of the CAFP’s Residency Funding Task Force and Medical Student and Resident Affairs Committee, and a member of the Board of Governors for Doctors Medical Center. Dr. Peter Broderick is truly a role model of the quintessential family physician, who is both a jack and a master of all trades. We are thrilled to honor him as CAFP’s 2011 Family Physician of the Year.

Professional Advancement | Personal Growth

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2011 Award for Educational Excellence in Honor of Barbara Harris

David E.J. Bazzo, MD The California Academy of Family Physicians is proud to name David Bazzo, MD, as the 2011 recipient of the Barbara Harris Award for Educational Excellence. “David Bazzo is one of the leading family medicine educators in the country,” said incoming CAFP President Carol S. Havens. “His tireless work to ensure clinical expertise has shaped the practice of thousands of physicians and countless patients over the span of two decades.” Dr. Bazzo has served as the family medicine lead and co-director of the Primary Care Core Clerkship at UCSD since 1999. In this unique program, third-year medical students are able to experience a full year of outpatient primary care, instead of the briefer clerkships more commonly available. At this time of a national primary care physician shortage, the program provides an important opportunity to recruit highly interested and motivated students into family and internal medicine specialties.” Since 2001, Dr. Bazzo also has served as associate director of the UCSD Physician Assessment and Clinical Education (PACE) Program, which is dedicated to assisting peer physicians who develop practice difficulties related to clinical competency. One important component of this program included assessing and providing remedial education for 300 primary care physicians in the California Department of Corrections and Rehabilitation, which helped improve the quality of care delivered over several years. Since 2008, he has continued this work as director of the UCSD California Correctional Health Care Improvement Program (C-CHIP). In addition to his PACE efforts, Dr. Bazzo has also contributed significantly to continuing medical education for his peers, developing programs for the San Diego Academy of Family Physicians, the California Academy of Family Physicians and the American Academy of Family Physicians, presenting at medical conferences and publishing in medical journals; to high school students, under a long-running National Institutes of Health grant; and to the community at large, through scores of television and newspaper interviews over the past few decades. Dr. Bazzo is a member of the CAFP’s Committee on Continuing Professional Development, and a member of the CME Leaders Institute faculty. Congratulations to 2011 Barbara Harris Award winner David Bazzo, MD.

63rd CAFP Annual Scientific Assembly • San Francisco

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2011 Philanthropist of the Year

Jimmy Hara, MD Several years ago, there was an advertising campaign at the Venice Family Clinic titled: “Why Dr. Hara is a Lousy Golfer.” The campaign was a creative way to explain Jimmy Hara, MD’s tireless schedule as a family physician, volunteer and philanthropist. Although he had received numerous accolades for his service to his patients and community, Dr. Hara quietly continued his relentless work as a humanitarian. Born in a Japanese internment camp during World War II, Dr. Hara knew at a very young age that he wanted to help others. While at medical school at UCSF, he began volunteering at one of the first free clinics in the country – Haight Ashbury Free Clinic. Dr. Hara continued his volunteer work throughout his residency, and despite sitting on more boards than one could imagine (on top of his already-hectic schedule as a physician), his desire to give back never wavered. His generosity includes making personal donations over the past five to 30 years to organizations having an impact on health care, including the Venice Family Free Clinic, Health Professionals Education Foundation Albert Schweitzer Medical Student Fellowship Program and Los Angeles Physicians for Social Responsibility. Dr. Hara has especially made an impact on students and residents, who struggled financially in the early stages of their careers. He would take some students and residents to dinner every night before volunteering at the Venice Family Free Clinic. He paid for all nine senior residents at Kaiser Sunset to attend the UCLA Family Practice Board refresher course. And he paid out-of-pocket for food at the FMIG talks at UCLA and USC. Given all that Dr. Hara does for family medicine, primary care and our communities, it is no wonder he has been such a leader within our field. “Now, as he is turning the page to the next chapter of his life, he has just retired from Kaiser Permanente after more than 35 years of service, I think it’s time to shed some light on the little known side of Dr. Hara, and his quiet philanthropy. The funds he and his wife Diane, donate to these causes help support and strengthen the programs and students that will take family medicine down the path of service that his long career and generosity have exemplified,” said Jose Avalos, MD. Congratulations to our 2011 Philanthropist of the Year, Dr. Jimmy Hara. And happy retirement! You can now catch up on your golf game.

Professional Advancement | Personal Growth

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2011 California Family Medicine Resident of the Year

Ashby Wolfe, MD, MPH, MPP The California Family Medicine Resident of the Year award is given to a resident who represents the finest characteristics of family medicine. This year, CAFP honors Ashby Wolfe, MD, MPH, MPP. Dr. Wolfe is being recognized for going above and beyond the call of duty to raise awareness about the unique role family physicians play in health care transformation. Dr. Wolfe is chief resident at the Department of Family and Community Medicine at the UC Davis Medical Center. As chief resident, she is an exemplary peer, student, leader and family physician. In her many roles, she represents the characteristics of a successful resident. She is passionately committed to actively advocating on behalf of her patients and the specialty of family medicine and inspiring her peers. As chief resident, Dr. Wolfe has an instrumental role in day-to-day problem solving and planning for the future success of the residency program. Along with several fellow residents, she created a Health Policy and Advocacy Committee (HealthPAC) at UC Davis, which provides a forum for medical students, residents and faculty from multiple departments to discuss active health policy issues that affect the health and well-being of the families for whom they care. Dr. Wolfe is extremely passionate about health policy and advocating for her specialty. She raises health care, public health and health policy issues at www.ashbywolfe.com. Last November, she was featured in a PBS News Hour story on the primary care physician shortage. Dr. Wolfe has also represented CAFP in legislative matters on several occasions, including an event with California Assembly member Richard Pan, MD at which Dr. Wolfe spoke to support Medical Injury Compensation Reform Act (MICRA) on behalf of CAFP. She’s also participated as: • Policy co-lead, Sacramento Local Action Network, National Physician’s Alliance. Dr. Wolfe attended monthly meetings and coordinated with local and statewide members to attend legislative hearings and community health advocacy meetings. • Co-leader, Resident Policy and Advocacy Committee, UC Davis Medical Center. Dr. Wolfe developed a resident-run policy interest group in the Department of Family Medicine at UC Davis. She coordinated group meetings, found guest speakers and planned monthly advocacy events. • Physician Consultant and Acting Medical Officer, Centers for Medicare and Medicaid Services, Region IX, San Francisco, CA. Dr. Wolfe coordinated regional outreach and education for the Physician’s Quality Reporting Initiative (PQRI). She was the co-lead for regional office pandemic flu and emergency preparedness and developed and provided training to surveyors and providers of long term care in California with a team from the Division of Survey and Certification. Finally, she regularly submitted analyses to the Regional Administrator. Dr. Wolfe received her medical degree from the School of Medicine at Stony Brook University Medical Center and her Masters of Public Policy and Public Health at the University of California, Berkeley. Congratulations to 2011 California Family Medicine Resident of the Year Dr. Ashby Wolfe.

63rd CAFP Annual Scientific Assembly • San Francisco

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2011 Heroes of Family Medicine

Bo Greaves, MD and Walt Mills, MD CAFP developed this award to honor family physicians who have gone above and beyond the calling of family medicine and who have so ably represented our specialty, our profession and our patients as to be called true “HEROES.” The 2011 award was presented at the Congress of Delegates/Town Hall meeting in March. Bo Greaves and Walt Mills are heroes of family medicine for many reasons, but they were presented the joint award for one: in recognition of the outstanding, transformative work they have done, and are doing, in Sonoma County to ensure that every person in Sonoma has a personal medical home by 2020. In 2007, the Sonoma County Board of Supervisors founded Sonoma Health Action, with the vision of making the county the healthiest in California by 2020. Bo co-chaired the primary care work group that ultimately brought about the Patient Centered Medical Home Learning Collaborative. The collaborative went live in March 2010. Bo and Walt had been co-conspirators on many projects over the years, having once practiced together, so it was only natural that Bo relied on Walt to help recruit a diverse learning collaborative which reached across traditional inter-institutional lines and brought nine offices from Sutter Health, Kaiser and community health centers together to support practice transformation and improvements. Bo and Walt epitomize the impact family physicians can have beyond the walls of the medical practices. Both have been active in their communities as well as in promoting family medicine there. As one big fan wrote, “The intent of the PCMH Collaborative is to ensure every Sonoma County citizen has access to a high performing medical home … (that will) change the lives of patients and health professionals … they are on their way to accomplishing that goal.” Bo served as the chair of the committee, senior advisor for the curriculum faculty for learning sessions and mentor for several practices. He had plenty of experience in the collaborative – as leader of CAFP’s New Direction in Diabetes Care, he took his practice through all the iterations of the Academy’s collaboratives. His partner in crime, Walt Mills, has toggled back and forth among three major duties. He spends 40 percent of his time in clinical work at the Kaiser Santa Rosa Medical Center, 20 percent administrative as chief medical officer of Southwest Community Health Centers, and 40 percent as associate medical director, UCSF, Santa Rosa Family Medicine Residency Program. His fourth major duty – from CAFP’s perspective – is as President of the Sonoma Chapter; he’s also the incoming President of the Sonoma County Medical Association. Walt was perfectly positioned as the great matchmaker. The vision they shared is coming to reality in Sonoma County. Congratulations to Bo Greaves and Walt Mills, CAFP’s 2011 Heroes of Family Medicine.

Professional Advancement | Personal Growth

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CAFP Foundation We want to thank each and every member who contributed to the Foundation in 2010-11. We know you had many requests for support, and appreciate the fact that you’ve chosen to remember family medicine in your charitable contributions.

2010 CAFP Foundation President’s Club Donors Keith Borglum Warren F Brandle, MD Jack Chou, MD Cynthia Cummings, MD Irina S. deFischer, MD Julian L. Delgado, MD Bo Greaves, MD Jeffrey Hankoff, MD Daniel E. Harvey, MD Carol Havens, MD Susan Hogeland, CAE Carla F. Kakutani, MD Jeffrey Luther, MD Eric Ramos, MD Shelly Rodrigues, CAE

2010 CAFP Foundation Donors Taejoon Ahn, MD, MPH Jonathan Anderson, MD Peter Arellano, MD Maria Barrell Evan Bass, MD Reynaldo Bayubay, MD David E. Bazzo, MD Sabrina Bazzo Thomas C Bent, MD Stuart Bloom, MD Robert C. Bourne, MD Karen Brent Simon Brumbauch, MD Carolyn F. Chase, MD Anthony Chong, MD Audrey D’Andrea, MD

Kamlesh M Desai, MD Mark Dressner, MD Emily A. Ebert, MD William Ebert, MD Jennifer Edwards, MD Christopher V. Flores, MD Kay Gamo, MD Caroline Garcia, MD Karen Gelphman, MD Alan Glaseroff, MD Anna M. Gonzalez, MD Howard Green, MD Steven A. Green, MD Carol S. Grench, MD Hal L. Grotke, MD Jeff Haney, MD Jimmy Hara, MD Kathryn Harvey, MD Harold Haughton, MD Cynthia Herzog, MD Romie Holland, MD Jay Iinuma, MD Asma Jafri, MD Douglas Jimenez, MD Alkarim S. Jina, MD Liz Kalve, MD Richard E. Katz, MD Cynthia Kear David Kilgore, MD Alexandra O Korin, MD Irene Lee Jay W. Lee, MD, MPH Marion Leff, MD Geoffrey Leung, MD, MEd Hector Llenderrozos, MD Samantha Malm, MD Theresa Manaloto, MD Anna-Lia Marilla, MD

Merritt S. Matthews, MD Nancy Mazza Marianne A. McKennett, MD Del Morris, MD Tim A Munzing, MD Chris Navalta Theresa Nevarez, MD Sandy Newman, MPH Robert Norman, MD Veronica C. Obodo-Eckblad, MD Adriana Padilla, MD Tiffany Pierce, MD Joseph J. Provenzano, DO Michelle S. Quiogue, MD Lee Ralph, MD Sumana Reddy, MD Jeannine M. Rodems, MD Eddie Rodriguez Larry Rosen Gloria Sanchez, MD Joel I. Sarachek Joseph E. Scherger, MD Michael Shaw, MD Lauren M. Simon, MD Marketa Spiro, MD Maureen Strohm, MD Robert F. Tomfohrde, MD Marc Tunzi, MD Susan Wilturner, MD Ramiro Zuniga, MD

2010 CAFP Foundation Donations “In Memory of”: Michael S Provenghi, MD, in memory of Mrs. Patricia Provenghi (“Grandma Pat”) Shelly B. Rodrigues, CAE, in memory of Nancy L. Beachly

2010 CAFP Foundation Chapter Donors Los Angeles County Academy of Family Physicians Orange County Academy of Family Physicians Riverside-San Bernardino Academy of Family Physicians

2010-2011 CAFP Foundation Corporate Sponsors AAFP Foundation Astellas Boehringer Ingleheim CS2day Inititative Lilly Pfizer Inc. PriCara Sanofi Aventis The California Endowment The Physicians Foundation We apologize if we missed your name. Please let us know so we can ensure proper recognition.

63rd CAFP Annual Scientific Assembly • San Francisco

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Join the Family Physicians Political Action Committee The Voice for Family Medicine in Sacramento Why Support FP-PAC? Contributions to the Family Physicians Political Action Committee (FP-PAC) go directly to candidates who support family medicine and our patients. Your contributions will ensure that the interests of family physicians and our patients are heard amid the deluge of proposals, appeals and requests that besiege candidates every day.

FP-PAC Contributes to Candidates on Both Sides of the Aisle Who Support a Broad Range of Pro-Family Medicine, Pro-Patient issues, including: ✓ Funding for family medicine training ✓ Adequate payment through Medi-Cal and other public programs ✓ Fair payment from private third-party payors ✓ Opposing unnecessary physician hassle ✓ Improving access to care ✓ MICRA malpractice protections Help strengthen family medicine’s voice in California; join your growing number of colleagues who have already given in 2011 and contribute to FP-PAC today! FP-PAC Board of Directors Carla Kakutani, MD, Chair Richard Zachrich, MD Steven Green, MD

Jack Chou, MD Irina deFischer, MD Eric Ramos, MD Lisa Ward, MD, MScPH

Karun Grossman, MD Jay Iinuma, MD, MBA Susan Hogeland CAE, ex-officio

For more information on FP-PAC, please go to www.familydocs.org/fppac Professional Advancement | Personal Growth

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2010 FP-PAC Contributors Help strengthen family medicine’s voice in California; join your growing number of colleagues who have already given in 2010-11 and contribute to FP-PAC today!

FP Champions Club

Maria Greaves, MD

Patricia Moore-Pickett, MD

(Monthly Donor)

Carol Havens, MD

Steven Pyke, MD

Jeremy Fish, MD

Susan Hogeland, CAE

Lee Ralph, MD

Hal Grotke, MD

Michelle Quiogue, MD

Shelly B. Rodrigues, CAE

Gil Soloman, MD

Elisabeth Renner, MD

Erika Schillinger, MD

Jeannine Rodems, MD

Alex Sherriffs, MD and Joan Rubinstein, MD Lauren Simon, MD

FP Ambassadors ($2,500 or more) Carla Kakutani, MD

Mario San Bartolome, MD Peter Swann, MD

Trudy Singzon, MD, MPH

Shabana Tariq, MD

John Testerman, MD

Silver Capitol Circle ($1,000 to $2,499)

Thomas Bent, MD

Judy and Eric Ramos, MD

Daniel Castro, MD

Platinum

Norma Jo Waxman, MD

General Donations

Tuan Doan, MD

(up to $99)

Patrick Dowling, MD

Samantha Malm, MD

($500 to $999)

Catherine Sonquist Forest, MD, MPH

Peter Broderick, MD

Lyman Bo Greaves, MD

Tiffany Pierce, MD

Irina deFischer, MD

Steve Green, MD

Jimmy Hara, MD

Nathan Hitzeman, MD

Student and Resident Platinum

Jay Lee, MD, MPH

Karen Hopp, MD

Delbert and Paula Morris, MD

Kelly Jones, MD

Student and Resident Gold

Paul Schommer, MD

Elisabeth Kalve, MD

($25)

Gold

Clarissa Kripke, MD

Cono Badalamenti, MD

Ronald Labuguen, MD

Aislinn Bird

Joseph Leonard, MD

Alisha Dyer, DO

Jeffrey Luther, MD

Edwin Kwon

Merritt Matthews, MD

Irene Lee-Klass, MD

Shannon McCune, MD

Sunny Pak, MD

($250 to $499) Taejoon Ahn, MD MPH Jose Arevalo, MD David Bazzo, MD Warren Brandle, MD, MS Mark Dressner, MD

Lisa Ward, MD, MScPH

($99 to $249)

($50)

Walt Mills, MD

63rd CAFP Annual Scientific Assembly • San Francisco

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Friends and Family Room Dolores Room

Saturday, May 14

7:30 am – 3:00 pm

Sunday, May 15

7:30 am – 12:45 pm

American Academy of Family Physicians represents more than 97,600 family physicians and medical students. The mission of the AAFP is to improve the health of patients, families, and communities by serving the needs of members with professionalism and creativity. Bristol-Myers Squibb is a global biopharmaceutical company committed to discovering, developing and delivering innovative medicines that help patients prevail over serious diseases. California Health Information Partnership and Services Organization (CalHIPSO) – Helping California clinicians successfully transition to electronic health records. CalHIPSO is a federally-designated Regional Extension Center funded by the Office of the National Coordinator, Department of Health and Human Services. California Prison Health Care Services – The mission of the California Prison Health Care Receivership Corp. is to raise to constitutional standards the level of medical care delivered to adult inmate patients incarcerated in California prisons. California Smokers’ Helpline is an online and telephone program to help people who want to kick the habit. Offers guide and links to local resources and telephone counseling. Kaiser Permanente – As the nation’s largest health care system, Kaiser Permanente is employing its resources and expertise to identify and foster health care innovation. Pathology, Inc. is California’s leading premier provider of anatomic pathology testing services for Women’s Health. As a trusted partner to physicians everything we focus on achieving better a patient outcome. Pharmavite, LLC, is the parent company of Nature Made® products; it makes and distributes high quality vitamins, minerals, and herbs and other nutritional supplements that will promote wellness and help maintain good health. Porter Novelli is an international marketing-based public relations firm specializing in consumer, convergence/technology, health care, and corporate affairs practices. PriCara, Division of Ortho-McNeil-Janssen Pharmaceuticals, is dedicated to Primary Care – Helping health care professionals meet their patients’ needs. Sanofi Pasteur, the vaccines division of sanofi-aventis Group, is the largest company in the world devoted entirely to human vaccines. Our driving goal is to protect people from infectious diseases by creating safe and effective vaccines. Touro University California College of Education and Health Sciences – The Joint MSPAS/MPH Program is committed to improving the health of individuals and communities with a focus on recruiting and serving underserved populations, by training clinicians who integrate the Physician Assistant and Public Health disciplines. Professional Advancement | Personal Growth

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CAFP congratulates all of its members celebrating their 30-40-50 and even 60-year membership anniversaries with the Academy. CAFP thanks each of you for your support and contributions to our efforts to champion family medicine and serve California family physicians. We look forward to continuing to work together for many years to come! Congratulations to the 92 CAFP members who are celebrating 30 Years with the Academy this year: Misha Askren, MD, FAAFP

Germaine Joan Frid, MD

James M. Pellegrin, MD

Joseph Au, MD, FAAFP

Neil S. Fruman, MD, FAAFP

Joseph Petrini, MD

Narciso M. Azurin, MD, FAAFP

Harry S. Fung, MD

Ngoc Minh Pham, MD, FAAFP

Craig S. Banta, MD, FAAFP

Patricia J. Galamba, MD

Martin Alan Quan, MD, FAAFP

Frank J. Baudino, MD

Stanley Gambrill, MD

Adelaide L. Randak, MD, FAAFP

Marvin I. Beams, MD

Theodore G. Ganiats, MD

Fred Leland Reitler, MD, FAAFP

Robert B. Benner, MD

Robert Lawrence Gong, MD, FAAFP

Gordon P. Reuben, MD, FAAFP

Barbara M. Bishop, MD, FAAFP

Howard I. Green, MD, FAAFP

Elizabeth M. Richards, MD

Carlo C. Brizzolara, MD, FAAFP

Inderjit Singh Grewal, MD, FAAFP

Joan E. Rubinstein, MD, FAAFP

Peter Watson Brown, MD

Janet D. Habegger, MD

Marcia E. Sablan, MD

Barry Alfred Brown, MD, FAAFP

Jefferson Hendrix, MD

James Michael Scheib, MD, FAAFP

Angela S. Calton, MD, FAAFP

Wesley L. Hoenshell, MD

Mark Scheier, MD, FAAFP

Gail G. Campofiore, MD

Dan D. Hopner, MD, FAAFP

Paul J. Schommer, MD

Benedict T. Carota, MD

Hin Chiu Hung, MD

Zubeda Arif Seyal, MD, FAAFP

Anand B.L. Chaudhary, MD, FAAFP

Royce Lewis Hutain, MD, FAAFP

Lawrence Gleason Shore, MD

James C. Cotter, MD

Ren N. Imai, MD, FAAFP

John J. Silbert, MD

Robert Daniel Daigle, MD, FAAFP

Rene M. Iway, MD, FAAFP

Gil Solomon, MD, FAAFP

Patrick Dennis Daley, MD, FAAFP

Ronald Garnet Kerr, MD

Peter George Stanley, MD, FAAFP

Jeffrey R. Davis, MD, FAAFP

Steven J. Leib, MD

Michael D. Stouder, MD, FAAFP

William R. Davis, MD, FAAFP

Brooks Martin, MD, FAAFP

John N. Strand, MD, FAAFP

Ricardo E. De Napoli, DO, FAAFP

Lawson Eugene McClung, MD, FAAFP

Maureen P. Strohm, MD, FAAFP

Shivinder S. Deol, MD, FAAFP

Robert M. McGrew, MD, FAAFP

Paul Swedberg, MD, FAAFP

Patrick T. Dowling, MD

Johanna Meyer-Mitchell, MD, FAAFP

Alexander Terrazas, MD

Donn Rollin Erickson, MD

Dennis W. Michel, MD, FAAFP

Alejandro C. Torres, MD, FAAFP

Janet A. Ewing, MD, FAAFP

Peter J. Minkoff, MD, FAAFP

Daniel Urrutia, MD, FAAFP

James Michael Fenlon, MD, FAAFP

Jimmie Dale Morrison, MD, FAAFP

James A. Westcott, MD, FAAFP

Charles C. Fenzi, MD, FAAFP

Antoine A. Mourra, MD, FAAFP

Vernon M. White, MD, FAAFP

Roger L. Fife, MD, FAAFP

William Earl Nation, MD, FAAFP

Thomas I. Wilson, MD, FAAFP

Dennis Patrick Flynn, MD, FAAFP

Janis Fae Neuman, MD

Leonard R. Worden, MD, FAAFP

Blaine Alsin Fowler, MD, FAAFP

Tieng V. Nguyen, MD, FAAFP

Patricia Yeung, MD, FAAFP

Peter Franks, MD

Anh Ngoc Nguyen, MD, FAAFP

63rd CAFP Annual Scientific Assembly • San Francisco

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Congratulations to the 24 CAFP members celebrating 40 years with the Academy this year: Hermine R. Akrawi, MD

David P. Frelinger, MD, FAAFP

Harvey S. Raskind, MD, FAAFP

Alex Michael Astorga, MD, FAAFP

Frederick F. Girard, MD

Alfio F. Saglimbeni, MD, FAAFP

Lawrence Elmer Bare, MD, FAAFP

David Edward Jones, MD

Russel B. Shields, MD

John M. Catlin, MD

Lawrence R. Leiter, MD, FAAFP

Robert E. Snyder, MD, FAAFP

Mary Chih-fang Chin, MD, FAAFP

Merritt S. Matthews, MD, FAAFP

Roy C. Springer, MD, FAAFP

S.N. Charles Cho, MD, FAAFP

John J. McDevitt, MD, FAAFP

Lynn M. Stanton, MD

Peter S. Davis, MD, FAAFP

Albert John Nelson, MD, FAAFP

Julio Michael Torres, MD, FAAFP

Kenneth B. Epstein, MD, FAAFP

Calmar Z. Nielsen, MD, FAAFP

David E. Wyatt, MD, FAAFP

Congratulations to the 35 CAFP members who are celebrating 50 years with the Academy this year: Daniel C. Anderson, MD

Percy Tim Wo Lui, MD, FAAFP

George Edward Schauf, MD, FAAFP

W. Clyde Ball, MD, FAAFP

Paul Melvin Mattson, MD, FAAFP

John Carlton Schmidt, MD, FAAFP

Carl Robert Blanche, MD, FAAFP

Merlin H. Mauk, MD, FAAFP

Harry Leroy Siemonsma, MD, FAAFP

Eugene Alfred Boston, MD, FAAFP

G.C. Mayer-Harnisch, MD, FAAFP

John Benjamin Slater, MD, FAAFP

Paul Dest, MD, FAAFP

Kenneth James McGrath, MD, FAAFP

Ronald Merton Sommer, MD, FAAFP

Raymond I. Downs, MD, FAAFP

Gerald Wayne Miller, MD, FAAFP

Joseph Struzzo, MD, FAAFP

Paul J. Dugan, MD, FAAFP

Antonio E.J. Monti, MD, FAAFP

Charles Harry Turner, MD, FAAFP

F. Harold Johnson, MD, FAAFP

Joe Carroll O’Banion, MD, FAAFP

Charles L. Weidner, MD

Arthur Leonard Keith, MD, FAAFP

Cesar S. Ortiz, MD, FAAFP

Carl H. Williams, MD, FAAFP

Charles Rex Lagrange, MD, FAAFP

Morton Pinsky, MD, FAAFP

John Morgan Wortley, MD, FAAFP

Robert James Lamb, MD, FAAFP

Harold L. Renollet, MD, FAAFP

Walter Edward Yury, MD, FAAFP

Donald Mack Lanning, MD, FAAFP

Erwin L. Samuelson, MD, FAAFP

Congratulations to the four CAFP members who are celebrating 60 years with the Academy this year: Herbert A. Holden, MD, FAAFP

Charles W. Libbey, MD, FAAFP

Bernard J. Korn, MD, FAAFP

John E. Mason, MD

Professional Advancement | Personal Growth

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Past Presidents

Ivan C. Heron, MD

1949

John Francis Quinn, MD

1982

Fredrick Ewens, MD

1950

Robert F. Tomfohrde, MD

1983

David F. Dozier, MD

1951

Harrison McCandless, MD

1984

L.C. Burwell, MD

1952

Richard C. Barnett, MD

1985

Francis T. Hodges, MD

1953

Sam W. Smith, MD

1986

Merlin L. Newkirk, MD

1954

Richard Katz, MD

1987

John G. Walsh, MD

1955

Merlin H. Mauk, MD

1988

Charles A. Preuss, MD

1956

Eugene Felmar, MD

1989

Joseph W. Telford, MD

1957

Robert Pedrin, MD

1990

A.J. Franzi, MD

1958

Harry W. Depew, MD

1991

Carroll B. Andrews, MD

1959

Mary Frank, MD

1992

Leon A. Desimone, MD

1960

Gregory Dunford, MD

1993

Clarence T. Halburg, MD

1961

Mattice Harris, Jr., MD

1994

Burt L. Davis, MD

1962

Joseph E. Scherger, MD, MPH 1995

John A.C. Leland, MD

1963

Stephen Brunton, MD

1996

Ralph L. Bennett, MD

1964

Paulette J. Adams, MD

1997

Horace F. Sharrocks, MD

1965

Norman Rosen, MD

1998

J. Blair Pace, MD

1966

Robert Bourne, MD

1999

Herbert A. Holden, MD

1967

Barbara Kostick, MD

2000

Dudley M. Cobb, MD

1968

Leonard Fromer, MD

2001

Frank W. Norman, MD

1969

Richard Zachrich, MD

2002

Edward H. Platz, MD

1970

Emily Ebert, MD

2003

Benson R. McGann, MD

1971

Dana Ware, MD

2004

Thomas Stern, MD

1972

Eric Ramos, MD

2005

Ransom Turner, MD

1973

Bo Greaves, MD

2006

Robert D. McGinnis, MD

1974

Carla Kakutani, MD

2007

Edwin Reithmayer, MD

1975

Jeffrey Luther, MD

2008

Holger Rasmussen, MD

1976

Thomas Bent, MD

2009

Nicholas P. Krikes, MD

1977

Jack Chou, MD

2010

Wilfred Snodgrass, MD

1978

Simon Brumbaugh, MD

1979

Hugh M. Upton, MD

1980

John P. Crivaro, MD

1981

CAFP would like to welcome Carol Havens, MD to her position as 2011-12 President. She joins a very distinguished list of fine family physicians and we know she will do an excellent job representing family medicine.

62nd CAFP Annual Scientific Assembly • San Francisco

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Board of Directors and Staff Directory Officers Carol Havens, MD Steve Green, MD Jack Chou, MD Mark Dressner, MD Del Morris, MD Jay Lee, MD

CAFP Foundation President President-elect Immediate Past President Speaker Vice Speaker Secretary/Treasurer

Robert Bourne, MD, President Shelly Rodrigues, CAE, Executive Director

Staff Susan Hogeland, CAE Executive Vice President Shelly Rodrigues, CAE, CCMEP Deputy Executive Vice President

District Directors Taejoon Ahn, MD, MPH Jose Arevalo, MD Evan Bass, MD Irina deFischer, MD Alan Glaseroff, MD (Rural Director) Aislinn Bird /Tona Rodriguez, MPH (Shared Student Director) Jimmy Hara, MD Jay Lee, MD (New Physician Director) Sharon Lin, DO (Resident Director) Susan Hutchinson, MD Adriana Padilla, MD Lee Ralph, MD Sumana Reddy, MD Lauren Simon, MD

Editor, California Family Physician

Cecilia Awayan Receptionist and Membership Assistant Karen Brent, MBA Director, Technology and Information Jane Cho Manager, Medical Practice Affairs Adam Francis Assistant Director, Government Relations and FP-PAC Coordinator Sophia Henry Manger, Membership Karisa Jauchon, CPA Chief Financial Officer Callie Langton, MPA Associate Director, Health Workforce Policy Cynthia Kear, CCMEP Senior Vice President

Michelle Quiogue, MD

Cody Mitcheltree Student and Resident Coordinator

AAFP Delegates

Chris Navalta Manager, Publications and Marketing

Jack Chou, MD Carla Kakutani, MD

AAFP Alternates Jeffrey Luther, MD Eric Ramos, MD

Professional Advancement | Personal Growth

Leah Newkirk, JD Director, Health Care Policy Tom Riley Legislative Advocate Marian Yee Manager, Continuing Medical Education

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CME Scorecard

Reporting your CME is Easy:

Please use this scorecard to keep track of the sessions you’ve attended at this meeting. It will be a helpful reminder to you as you file your CME report with AAFP. Questions? Ask any CAFP staffer.

Session

www.aafp.org

www.

aapf.o

Fast, efficient and you have control!

Attended Credits Notes

Saturday May 14 Keynote: Abraham Verghese, MD

Yes No

LGBT Health Issues

Yes No

Male Urinary Tract Symptoms

Yes No

Team Approach to Diabetes

Yes No

1.25

Prescription Drug Abuse

Yes No

Barriers in Depression

Yes No

Circadian Rhythms

Yes No

1.25

Team Diabetes/PI Workshop

Yes No

1.5

Cerebrovascular SAMs

Yes No

Primary Prevention of Dementia

Yes No

Hepatitis B Update

Yes No

MRSA

Yes No

Head Trauma, Concussions and TBI

Yes No

1.25

2 Minutes, 2 Slides, 2 Questions

Yes No

.75

Health Behaviors SAMs

Yes No

Yes No

Yes No

Sunday May 15

Professional Advancement | Personal Growth

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San Francisco Restaurant Recommendations* A-16 2355 Chestnut St. 771-2216 – This restaurant has casual dining and delicious food – especially their woodfired pizzas and fresh mozzarella. $$$

Lulu 816 Folsom 495-5775 – trendy, loud, family-style food featuring wood-fired ovens. Quite good and fun to share. $$

Yabbie’s 2237 Polk Street 474-4088

Acquarello 1722 Sacramento Street

Masa’s 648 Bush 989-7154 – one of the finest restaurants in the country, with prices to match. Impeccable service – almost choreographed. $$$$

Zuni Café 1658 Market 552-2522 –

567-5432 – subtle, beautiful food. Quietly successful for years. $$$$

Aqua 252 California Street 956-9662 – Contemporary seafood in elegant surroundings. $$$$

Boulevard 1 Mission Street (foot of Mission) 543-6084 – French bistrostyle decor and American/California food. $$$$

Da Flora 701 Columbus at Filbert 981-4664 – This tiny Venetian restaurant is not for the run-of-the-mill tourist. The menu is small – you may want to ask about the entrees to be certain they have what you like. $$

Farallon 450 Post Street 956-6969 – Elegant seafood , stylish submarine decor. $$$ Fringale 570 4th Street 543-0573 – if you can get in, go. Very well-made French food at Bistro prices. $$

Gary Danko 800 North Point Street, 415-749-2060 – French/Californian – a fine place. $$$$

Greens Fort Mason 771-6222 – fine vegetarian dining by Zen Buddhists; fresh, home grown produce and baked breads, great view of the water/Bay. Worth the trek. $$$

Harry Denton’s Bar & Grill 161 Steuart Street 882-1333 – Big, good food, reasonably priced. Sometimes the music is loud at night. $$ Jardiniere 300 Grove 861-5555 – You must eat there to believe it. Beautifully prepared food by one of the hottest chefs in the country, Tracy Des Jardin. $$$$

La Folie 2316 Polk Street 776-5577 – consistently one of the finest French restaurants in town. Prix fixe is a good bet to keep costs down. $$$$

Palomino 345 Spear St., – Palomino’s sweeping Bay Bridge views, lively bar and a Mediterranean-inspired menu is a waterfront favorite. Reasonably priced. It’s a chain. $$ Perbacco 230 California Street

Great seafood in a charming, neighborhood location. Excellent value – great array of shellfish, especially oysters. $$ wood fired oven specialties along a variety of oysters make this a favorite. The roast chicken for two (takes 45 minutes) is well worth the wait. $$$

Cheaper Eats – For wandering about, quick lunches, cheap dinners.

955-0663 – excellent Italian; all salami and pastas homemade on the premises. Next door to Tadich Grill. $$

• Bohemian Cigar Store 566 Columbus – Italian sandwiches, coffees.

Postrio 545 Post 776-7825 – Wolfgang

• Cha Cha Cha 1801 Haight – great tapas, long wait after 6. Good people watching.

Puck’s San Francisco venture that is always packed, but don’t go there for an intimate meal. Try the lobster club at lunch. $$$$

Rose Pistola 532 Columbus Avenue 399-0499 – Casual family-style Italian in a stylish setting. For a little extra fun try sitting at the counter overlooking the kitchen staff. $$

Slanted Door One Ferry Building #3 861-8032 – Spectacular Vietnamese food; just try to get in. Now in the Ferry Building. Allow time to walk around the splendid food/wine shops. $$$ Tadich Grill 240 California 391-1849 – classic SF restaurant – waiters toss gallon jugs of wine back and forth behind the bar; excellent, fresh grilled fish. No reservations; always a wait. $$$

Tommy Toy’s 655 Montgomery Street 397-4888 – Delectable Chinois food – combination of French and Chinese heavy on the Asian accent. Lovely decor. $$$

Town Hall 342 Howard Street 9083900 – South of Market. Town Hall was designed to evoke a communal gathering place with seasonally inspired menu and glitzy but casual decor. $$

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• Café Bastille 22 Belden – excellent French food at reasonable prices; steak and pommes frites to die for. No reservations. Lunch and dinner. Belden Alley has a wonderful array of good restaurants, including Plouf below. • Café Claude 7 Claude Lane. Ditto Bastille. • Café Tiramisu 28 Belden 421-7044 – Italian (reservations possible). • LaCucina 2136 Union 921-4500 – a nice little piece of North Beach. • Plouf 40 Belden 986-6491 – French seafood bistro.

*Please call before going to any restaurant on this list. Things change rapidly in the restaurant business!

Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð

San Francisco

Legend 1. Grand Hyatt Hotel 21. San Francisco Marriott 22. Lombard Street, aka “The Crookedest Street” 23. Sony Metreon (Dining, Entertainment) 24. Chinatown 25. Coit Tower 26, Ghiradelli Square (Shopping, Chocolate) 27. Pier 39 (Shopping, Dining, Fun) CAFP’s Office

63rd CAFP Annual Scientific Assembly • San Francisco

Schedule for Saturday, May 14, 2011_____________________________________

8:30-9:00 am

ASA Grand Opening

Page

Geoffrey Leung, MD, Chair; Jack Chou, MD, CAFP Outgoing President;

9:00 - 10:00 am

The Importance of Bedside Medicine and Physical Examination in a Time of Advanced Technology

Abraham Verghese, MD

10:00-11:00 am

LGBT Primary Care Health Priorities

Shane Snowdon and Caitlan Ryan, PhD

11:30-12:30 pm

Male Urinary Tract Symptoms: Overactive Bladder or Benign Prostatic Hyperplasia

and Carol Havens, MD, CAFP Incoming President

Stephen Kraus, MD

12:30-1:45 pm

Lunch and Learn Team Diabetes â&#x20AC;&#x201C; Diabetes Care: A Team Approach 73 How We Can Take Better Care of Mr. Sanchez

Bo Greaves, MD; Chris Saddler, PA-C; and Loren Lorenzo, APRN

12:30-5:30 pm

SAMs Group #1: Cerebrovascular Disease

Cheri Olson, MD

1:45-2:45 pm

Prescription Drug Abuse/Dependence

Pre-Registration Required

Carol Havens, MD

Invitation Only

Team Diabetes / PI Teams

3:15-4:15 pm

Breaking Down the Walls: Tackling the Barriers to Treating Depression

Thomas Bent, MD

104

4:15-5:30 pm

Circadian Rhythm Disorders: Asking the Right Questions

119

2:00-3:30 pm

S A T U R D A Y

Larry Culpepper, MD and Jeffrey Luther, MD

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Session #1: Saturday, May 14, 9:00-10:00 am

Keynote Address by Abraham Verghese, MD

“The Importance of Bedside Medicine and Physical Examination in a Time of Advanced Technology”

Abraham Verghese, MD Professor, Department of Medicine Stanford University

Learning Objectives 1. Emphasize bedside technique: not just a theoretical knowledge of how to percuss, but actual instruction and supervision, repetition and feedback.

2. Use of bedside exam skills as a valuable way for setting priorities with complicated patients, a way of establishing a hierarchy in a “problem” list that scrolls off the page.

3. Correlate the relevant anatomy and physiology with disease in a more direct way: the wonderful technology of imaging should allow more direct correlation and sharpening of skills. 4. Promote physical exam findings as valid phenotypic markers, rather than as archaic collections of eponyms; in the genomic era it is clear that the phenotypic markers of disease are often more meaningful and predictive than the genotype.

About the Speaker Dr. Abraham Verghese completed his medical education at the Madras University Medicine in India and completed his fellowship and residency at East Tennessee State University. He also received a Masters of Fine Arts from The University of Iowa Fiction Program. Dr. Verghese is the New York Times bestselling novelist of Cutting for Stone and previously wrote, My Own Country: A Doctor’s Story. He has said his orderly experience at an American hospital affirmed his strong empathy for the suffering of patients and the need for him to complete his medical education. Dr. Verghese’s work in inner city community hospitals transformed him from being “homoignorant” into developing a deeper understanding of his patients and their care. He developed a formal humanities and ethics curriculum that was incorporated into four years of medical study in San Antonio and continues to invite his medical students to accompany him in routine bedside visits to demonstrate the value of the physical examination in creating a two-way relationship that benefits patients, their families, and the physician.

Disclosure Dr. Verghese declares that in the past 12 months neither he nor members of his immediate family have had financial relationships with the manufacturers of goods or services discussed in this activity.

Support This session is supported by a grant from the CAFP Foundation.

63rd CAFP Annual Scientific Assembly • San Francisco

Session #2: Saturday, May 14, 10:00-11:00 am Lesbian, Gay, Bisexual and Transgender Primary Health Care Priorities

Shane Snowdon Director, Center for LGBT Health and Equity University of California San Francisco San Francisco, CA

S A T U R D A Y

Caitlin Ryan, PhD, ACSW Family Acceptance Project, Marian Wright Edelman Institute College of Health and Human Services San Francisco State University San Francisco, CA

Activity Description This session will offer complementary presentations on the value of the resources available to support families to understand and care for their LGBT youth.

Learning Objectives

1. Engage in an open dialogue with patients about the impact of family response to an adolescent’s LGBT identity on their health and mental health

2. Identify specific family reactions to an adolescent’s LGBT identity that increase risk and help promote well-being and protect LGBT youth from risk

Disclosures Shane Snowdon and Caitlin Ryan declare that in the past 12 months neither they nor members of their immediate families have had financial relationships with the manufacturers of goods or services discussed in this activity.

Faculty Bios Shane Snowdon is the founding director of the Center for LGBT Health and Equity at UCSF, the only LGBT office in a health care or health education setting in the US. In that role since 1999, she has taught, consulted, and developed curriculum around LGBT health concerns for schools of medicine and nursing throughout the country. She also convenes UCSF’s annual LGBTQI Health Forum for health professional students statewide, and in 2010 she organized the nation’s first Summit on LGBT Issues in Medical Education, attended by more than half the nation’s medical schools. In addition, she provides training and consulting to hospitals, clinics, and medical societies statewide and nationally, sharing best practices for equitable, inclusive care of LGBT patients and their families. She has received the Lifetime Achievement Award of the Gay & Lesbian Medical Association, serves on the National Advisory Council of the LGBT Healthcare Equality Index, and was honored with UCSF’s Award for Exceptional University Service. She attended Harvard College,

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..and previously served as executive director of an urban domestic violence agency, a national womenâ&#x20AC;&#x2122;s cancer organization, and a major employment and training program for ex-inmates. Caitlin Ryan, PhD, ACSW, completed her doctoral degree in public policy at Virginia Commonwealth University and received her clinical social work degree at Smith College School of Social Work. Dr. Ryan developed the Family Acceptance Project with Rafael Diaza, PhD, at San Francisco State University. This is a unique research and service organization that intervenes with families to support adolescents coming out to their families. The research arm of FAP recently published a peer-reviewed article about the long-term impact of school victimization on the mental and physical well-being of LGBT adolescents. It also published a peer reviewed article on the significance of family acceptance of their LGBT youth and its value to their physical and mental health and development, including reducing risky negative behaviors. Dr. Ryan was the Director of Adolescent Health Initiatives at Cesar E. Chavez Institute, College of Ethnic Studies, and Director of Policy Studies, Institute on Sexuality, Inequality, and Health, in the Human Sexuality Studies Program, all at the San Francisco State University.

Support: This session is supported by the CAFP Foundation, via a grant from The California Endowment. Resource guides were provided by Kaiser Permanente.

63rd CAFP Annual Scientific Assembly â&#x20AC;˘ San Francisco

KEY LGBT HEALTH RESOURCES

Prepared by Shane Snowdon, Director | UCSF Center for LGBT Health & Equity shane.snowdon@ucsf.edu | 415.502.5593 | lgbt.ucsf.edu

General information about LGBT people and issues: • Human Rights Campaign: www.hrc.org • National Gay & Lesbian Task Force: www.ngltf.org • National Center for Transgender Equality: nctequality.org • Parents, Families & Friends of Lesbians & Gays (PFLAG): www.pflag.org

S A T U R D A Y

State & national LGBT health initiatives and organizations: • California LGBT Health & Human Services Network: • • • • • •

www.eqcai.org/site/c.mtJYJbMKIoE/b.4445239/k.915E/Network_Members.htm Straight for Equality in Healthcare (PFLAG): www.straightforequality.org/healthcare Gay & Lesbian Medical Association: www.glma.org American Medical Association GLBT Advisory Committee: www.ama-‐assn.org/ama/pub/about-‐ama/our-‐people/member-‐groups-‐sections/glbt-‐ advisory-‐committee.shtml IOM Report on LGBT Health Issues and Research Gaps & Opportunities: www.iom.edu/Activities/SelectPops/LGBTHealthIssues.aspx National Healthcare Equality Index (HRC’s annual hospital survey): www.hrc.org/hei National LGBT Health Coalition: lgbthealth.net

LGBT health training materials: • The Fenway Guide to Lesbian, Gay, Bisexual & Transgender Health, American College of • • • •

Physicians: www.acponline.org/atpro/timssnet/catalog/books/fenway.htm Fenway Institute Learning Modules: www.fenwayhealth.org/site/PageServer?pagename=FCHC_ins_fenway_EducPro_modules LGBTQ Cultures: What Health Care Professionals Need to Know About Sexual & Gender Diversity, Michele J. Eliason et al. (online text with nursing CE credits): www.nursingcenter.com/prodev/static.asp?pageid=928987 Kaiser Permanente Provider’s Handbook on Culturally Competent Care: LGBT Population: www.madisonstreetpress.com/cgi-‐bin/shop.shtml?id=25 or call 510-‐271-‐6663 to order Clinical Guidelines for Care of LGBT Patients (Gay & Lesbian Medical Association): http://www.glma.org/_data/n_0001/resources/live/Welcoming%20Environment.pdf

Information & materials for creating a welcoming environment: • • • •

Transgender Law Center (tips for welcoming transgender patients): transgenderlawcenter.org UCSF Medical Center Protocols & Practices (featured in AHRQ Innovations Exchange): www.innovations.ahrq.gov/content.aspx?id=2737 American Cancer Society (brochures on LGBT cancer & smoking): contact local ACS office GLBT Health Access Project (posters and protocols): www.glbthealth.org

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KEY LGBT HEALTH RESOURCES (continued)

Prepared by Shane Snowdon, Director | UCSF Center for LGBT Health & Equity shane.snowdon@ucsf.edu | 415.502.5593 | lgbt.ucsf.edu

Reports on LGBT health disparities: • When Health Care Isn’t Caring (Lambda Legal): www.lambdalegal.org/health-‐care-‐report • The Health of Aging LGB Adults in California (UCLA): •

healthpolicy.ucla.edu/NewsReleaseDetails.aspx?id=79 CAP Report on LGBT Health Disparities: www.americanprogress.org/issues/2009/12/lgbt_health_disparities.html

Population-‐specific LGBT health information: • Primary Care for Lesbians and Bisexual Women, Sally Mravcak, MD: • • • • • • • • •

www.aafp.org/afp/20060715/279.html Lesbian Health 101: A Clinician’s Guide, Patty Robertson, MD & Sue Dibble, DNSc, eds.: nurseweb.ucsf.edu/public/npress/ord-‐lh.htm CA DPH Resources for Clinicians Treating STDs in MSM: stdcheckup.org Magnet (SF-‐based health website for MSM): new.sfaf.org/magnet/ UCSF Anal Cancer Screening Information: id.medicine.ucsf.edu/analcancerinfo/diagnosis/screening.html Bisexual Health: An Introduction & Model Practices: www.thetaskforce.org/reports_and_research/bisexual_health Bisexual Invisibility Report (SF Human Rights Commission): www.sf-‐ hrc.org/index.aspx?page=1 Clinical Guidelines for Transgender Care, Trans Care Project, Vancouver, Canada: www.vch.ca/transhealth/resources/careguidelines.html UCSF Center of Excellence for Transgender Health: transhealth.ucsf.edu Endocrine Society Guidelines for Treatment of Transsexual Persons: www.endo-‐society.org/guidelines/Current-‐Clinical-‐Practice-‐Guidelines.cfm

Information for/about LGBT youth, families, and elders: • The Trevor Project (suicide hotline for LGBTQ youth): www.thetrevorproject.org/ • GLSEN (Gay, Lesbian & Straight Education Network): glsen.org • Gay/Straight Alliance Network: www.gsanetwork.org • California Safe Schools Coalition: www.casafeschools.org • Family Acceptance Project (resources for families of LGBT youth): familyproject.sfsu.edu/ • Family Equality Council: www.familyequality.org • COLAGE (Children of Lesbians & Gays Everywhere): www.colage.org • National Resource Center on LGBT Aging: www.lgbtagingcenter.org/

63rd CAFP Annual Scientific Assembly • San Francisco

The Family Acceptance Project San Francisco State University

S A T U R D A Y

The Family Acceptance Project™ (FAP) is a research, intervention, education and policy initiative that studies the impact of family acceptance and rejection on the health, mental health and well-being of lesbian, gay, bisexual and transgender (LGBT) youth. Developed in 2002 by Caitlin Ryan, PhD and Rafael Diaz, PhD at San Francisco State University, the Family Acceptance Project™ includes the first major study of how families respond and adapt when LGBT youth come out during adolescence. Most importantly, FAP provides the first empirical findings that link specific behaviors that families use to express acceptance and rejection of their LGBT children with health and mental health in adulthood, including substance abuse, suicide and HIV as well as self-esteem and well-being. Based on this research, we are currently developing a new evidence-based, family model of wellness, prevention and care to promote well-being and decrease risk for LGBT children and adolescents. We are working with professional associations, government agencies, providers and advocacy groups to share our findings and new family approach across the U.S. and with other countries.

Need for the Project:

Although LGBT youth have been self-identifying at younger ages than lesbian and gay adults in earlier generations, prior to this project, little was known about how families adapt to their children’s LGBT identity and how this affects their health and well-being.This work is especially important since studies show that young people become aware of sexual attraction, on average, at about age 10. Nevertheless, few services are available for families of LGBT adolescents, particularly families of color. So families and caregivers have little information or support to deal with sexual orientation and gender identity issues when young people come out during childhood and adolescence, as has become increasingly normative. Family Acceptance Project™ Building healthy futures for children and youth. fap@sfsu.edu 415-522-5558 http://familyproject.sfsu.edu

What We Did:

Working closely with many community groups, providers, families and youth, we used an innovative participatory family-based approach to study risk, resiliency and health concerns in LGBT young people. Our research includes in-depth individual interviews in English and Spanish with LGBT adolescents and their families who were accepting, ambivalent and rejecting of their children’s LGBT identity. We identified more than 100 specific behaviors that families use to express acceptance and rejection of their LGBT children and then measured the impact of each of these family behaviors on the health and mental health of LGBT young people. (continued)

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What We Found:

Based on our research, we are finally able to show empirically that families and caregivers have a dramatic and compelling impact on their LGBT children’s health, mental health and well-being. LGBT young people whose parents and caregivers reject them report high rates of depression, substance abuse, suicide attempts and risk for HIV infection. Conversely, LGBT young people whose parents support them show much higher rates of self-esteem and greater well-being, with lower rates of health and mental health problems.

Because we measured family and caregiver acceptance and rejection of their LGBT children, for the first time, we can show families how their words, actions and behaviors affect their LGBT children’s health, mental health and well-being. We can show ethnically and religiously diverse families how to reduce their children’s risk by decreasing specific rejecting behaviors and how to increase their well-being by engaging in supportive behaviors. In follow up sessions with very diverse families, we have been able to motivate families to modify rejecting behaviors to decrease their LGBT children’s risk and to increase their well-being. We have also studied what happens in families when LGBT and gender variant children and youth are victimized in school and how to help parents, foster parents, families and caregivers prevent and manage school victimization. Our new family intervention approach educates and empowers diverse parents and caregivers to advocate for their LGBT children in families, schools and communities and shows parents how advocating for their LGBT children promotes their well-being and protects them against serious health and mental health risks, including suicide and HIV.

Culturally Appropriate Interventions: FAP received a matching grant from the Robert Wood Johnson Foundation to develop culturally appropriate interventions based on our research to help diverse families increase support for their LGBT children, decrease their LGBT children’s risk and promote their well-being. We are developing this new family model of prevention and care in collaboration with Child and Adolescent Services at San Francisco General Hospital / University of California, San Francisco. We work with a wide range of community groups in carrying this out. Our findings and interventions aim to: ·

Significantly improve the health, mental health and quality of life for diverse LGBT children and their families.

Strengthen diverse families, decrease social stigma and help maintain many LGBT children and adolescents in their homes that would otherwise end up out-of-home, in custodial care or homeless.

Substantially reduce the cost of care, personal suffering and loss to society by preventing major negative outcomes in at risk children and adolescents.

Educate and mobilize parents and caregivers to advocate for their LGBT children to prevent school victimization and to promote supportive school environments.

Inform legal decisions and develop appropriate public policy related to sexual orientation and gender expression.

Promote acceptance and support for LGBT and gender variant children, youth and adults by educating and engaging diverse families and communities.

Further Information:

FAP is supported by foundation grants and individual donors. For additional information or to make a tax-deductible contribution, contact Caitlin Ryan, PhD, ACSW, Director, Family Acceptance Project™ - San Francisco State University at: caitlin@sfsu.edu or 415-522-5558.

63rd CAFP Annual Scientific Assembly • San Francisco

Session #3: Saturday, May 14, 11:30 am-12:30 pm Male Lower Urinary Tract Symptoms:

Overactive Bladder or Benign Prostatic Hyperplasia

Stephen Kraus, MD Professor and Vice Chairman, Department of Urology Head, Section of Female Urology, Neuro-Urology and Voiding Dysfunction University of Texas Health Science Center, San Antonio

S A T U R D A Y

Activity Description Using two cases as the basis of discussion, Dr. Krause will explore the significant questions to direct the physical examination that leads to the appropriate differential diagnosis and developing an appropriate treatment plan for male patients.

Learning Objectives

1. To become familiar with the different types of lower urinary tract symptoms (LUTS) in men and their causes. 2. To become familiar with the diagnostic evaluation of male LUTS.

3. To understand the different treatment options for male LUTS and how they can be integrated into practice.

Disclosure Stephen Krause, MD, is the Course Director and Faculty of Laboratory Medical Technologies. He is also a research trial design consultant for Pfizer.

Faculty Bio Dr. Kraus holds numerous appointments at the University of Texas Health Science Center, San Antonio. He is professor and vice chair of the Department of Urology where he heads the section of female urology, neuro-urology, and voiding dysfunction. In addition, Dr. Kraus heads the Urology and Urodynamics Unit at the Spinal Cord Injury Center at the Audie Murphy VA Hospital and serves as medical director of the South Texas Pelvic Floor and Bladder Center, part of the University Hospital Urodynamics Laboratory and Incontinence Center.

Support This session is supported by unrestricted grants from Pfizer and Astellas, as a part of the Successful Strategies for Supporting OAB Patients collaborative.

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Male Lower Urinary Tract Symptoms: BPH vs OAB? Stephen Kraus MD, MS, FACS Professor and Vice Chairman Department of Urology

Faculty Disclosure 



Dr. Kraus declares that he is the Course Director and Faculty of Laboratory Medical Technologies. He is also a research trial design consultant for Pfizer.



This activity is supported by unrestricted education grants to the Successful Strategies to Support Your OAB Patients collaborative from Pfizer and Astellas.

Case 1: Roy Roy is a 62 year old male presenting with LUTs. Specifically, he complains of:  nocturia 3-4 times/night  weak stream, often feels the need to push and strain  Also with urgency and hesitancy



– he feels he has to rush to bathroom when he gets the urge but then he has to wait until his urination actually starts – Becomes an issue because he is a foreman and sometimes has limited bathroom access

Symptoms have been present for a few years but have become progressively worse, especially the nocturia which finally drove him to see you now

63rd CAFP Annual Scientific Assembly • San Francisco

Case 1: Roy 1.1a What question is most important? 1. Has he had blood in urine? 2. Has he had UTI or dysuria? 3. How much fluid does he drink and does he drink at night time? 4. Does he have any other medical problems that might contribute to his urinary problems 5. All of the above

S A T U R D A Y

Case 1: Roy Roy’s medical history:  PMHx: for GERD and hypertension.  Meds: esomeprazole & enalapril.  PSHx: appendectomy, knee arthroscopy  Allergies: NKDA  SHx: denies tobacco, (+) ETOH—“few beers per day”  FHX: negative for DM, CAD, Negative for Prostate Cancer

Case 1: Roy Roy’s physical exam:  Majority of exam is noncontributory  GU Exam:

– Normal male genitalia, circumcised – Scrotal exam is normal, no nodules or tenderness – Digital rectal exam: slightly enlarged prostate, no nodules

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Case 1: Roy

1.2a Based on the above information, which of the following should you definitely obtain? 1. 2. 3. 4.

Urinalysis and bladder diary Uroflow Cystoscopy Chemistry panel with creatinine

Case 1: Roy Follow-up  His urinalysis is negative  After discussing prostate cancer screening, patient opts for PSA which returns 2.2 (0-4.0).  He does a 2-day diary

– voids 10-12x per day including 4 voids per night. – You note he voids q 1-2 hours at in morning and at night but he seems to last longer in the afternoon.

Case 1: Roy 1.3a What should be included in your recommended treatment plan? 1. Initiate course of alpha blockers 2. Cut back on fluids especially coffee and night time beers 3. Phenylephrine 4. Refer to urologist 5. Both 1 and 2

63rd CAFP Annual Scientific Assembly • San Francisco

Case 2: Hector Hector is a 69 year old male with complaints of:  urgency, frequency q 1 hr, nocturia x 4.  Bothered by urgency and urge leakage

 

– frequently spots underwear when gets urge but can’t get to bathroom in time. – Symptoms more bothersome at night and has leakage at night.

He has been on terazosin 5mg QHS for 5 years, reports force of stream is stable and denies strain void. Hector denies hematuria or dysuria

S A T U R D A Y

Case 2: Hector His symptoms worsened after knee surgery, and you learn he has had problems with chronic constipation that are much worse after knee surgery. Prior to knee surgery, he had:  frequency q 90-120 minutes  rare spot leakage in underwear on way to bathroom.  Had nocturia x2-3 and was dry at night.

Case 2: Hector

2.1a What is most likely causing his urgency and frequency? 1. 2. 3. 4.

BPH Overactive bladder Urinary tract infection Prostate cancer

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Case 2: Hector  PMHX: HTN, arthritis  PSHX: Arthoscopic Knee Surgery  Meds: Vicodin, Diclofenac, Enalapril  Soc Hx: Retired, no etoh/tob  PE:

– Abd:soft, nontender, no organomegaly – No palpable suprapubic mass – Normal GU Exam – DRE: prostate 30 gm no nodules

 Labs: PSA 1.6, UA negative

Case 2: Hector 2.2a What do you do first? 1. 2. 3. 4.

Address constipation Add anticholinergic Increase terazosin to 10mg QHS DDAVP

Case 2: Hector Three Months Later:  His constipation is better. He is off vicodin.  Urinary symptoms are better but not perfect.

– Nocturia back to x2. Dry at night. – Daytime urgency persists. Still frequent spotting in underwear when gets urge and unable to get to bathroom in time which is bothersome.

63rd CAFP Annual Scientific Assembly • San Francisco

Case 2: Hector 2.3a What is your best option? 1. Continue as is 2. Add anticholinergic 3. Add behavioral modification, pelvic floor exercises 4. Add finasteride

S A T U R D A Y

Disclosure The faculty and planners of this activity are required to disclose any conflicts of interest: Stephen Kraus, MD â&#x20AC;˘ Advisor Board, Consultant and lecturer for Pfizer; and â&#x20AC;˘ Consultant for Laborie Medical The planners of this activity have nothing to disclose.

Disclosure This activity is supported by independent educational grants from Astellas and Pfizer.

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Goals and Objectives 



To become familiar with the different types of lower urinary tract symptoms (LUTS) in men and their causes To become familiar with the diagnostic evaluation of male LUTS To understand the different treatment options for male LUTS and how they can be integrated into practice

Alphabet Soup     

BPH BPE BOO OAB LUTS

Alphabet Soup 

Benign Prostatic Hypertrophy (BPH) – – – –



Histologic BPH Macroscopic glandular enlargement BPH related symptoms Benign prostatic enlargement

Bladder outlet obstruction (BOO)

– Male and Female – Male: Typically prostate, urethral stricture, bladder neck contracture (post op), – Female: urethral obstruction (post op!!) prolapse



Overactive Bladder

– Male and female – Bladder is cause (involuntary contractions, increased sensory)



Lower Urinary Tract Symptoms (LUTS)

63rd CAFP Annual Scientific Assembly • San Francisco

Male Lower Urinary Tract Symptoms (LUTS) Storage

Voiding

Postmicturition

Frequency

Hesitancy

Dribbling

Nocturia

Poor flow

Incomplete emptying

Urgency

Intermittency

Incontinence

Straining

S A T U R D A Y

Abrams P et al. Neurourol Urodyn. 2002;21:167-178

Male Lower Urinary Tract Symptoms (LUTS) Storage

Voiding

Postmicturition

Frequency

Hesitancy

Dribbling

Nocturia

Poor flow

Incomplete emptying

Urgency

Intermittency

Incontinence

Straining

Obstructive Abrams P et al. Neurourol Urodyn. 2002;21:167-178

Male Lower Urinary Tract Symptoms (LUTS) Storage

Voiding

Frequency

Hesitancy

Dribbling

Nocturia

Poor flow

Incomplete emptying

Urgency

Intermittency

Incontinence

Straining

Postmicturition

Irritative Abrams P et al. Neurourol Urodyn. 2002;21:167-178

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Male LUTS Increases with Age

Nordling, Exp Gerontol 2002;37(8–9):991–9;

Causes: Lower Urinary Tract Symptoms 

Bladder outlet obstruction

– Benign prostatic hypertrophy (BPH) » Aka: benign prostatic enlargement

– Urethral stricture, Bladder neck contracture – Prostate cancer



Bladder: – – – – –

Involuntary detrusor contraction (OAB) Detrusor hypo- or areflexia Intrinsic bladder wall disorder -poor ‘compliance’ Bacterial cystitis, Interstitial cystitis, Bladder neoplasm

What is BPH?   

Technically, a histological diagnosis No bearing on patient symptoms or impact Incidence is age dependent – Typically NOT a young man’s disease

63rd CAFP Annual Scientific Assembly • San Francisco

BPH 

First phase

– Develop small hyperplastic nodules in peri-urethral area – Increase in number over years



Second phase (typically >60 years old)

– Dramatic and simultaneous increase in size of glandular nodules – Also with changes in stromal tissue » Resembles of developmental mesenchyme

– Considered “distorted reawakening of embryonic process in adult life”

S A T U R D A Y

Bushman, Urol Clin N Am 36 (2009) 403–415

Bladder Outlet Obstruction 20 BPH

 Prostate

grows with age and time

 Pressure

on the urethra restricts urine flow

Prevalence of BPH     



20% of men age 41-50 40% of men age 51-60 70% of men age 61-70 80% of men age 71-80 90% of men age 81-90

25-50% microscopic & macroscopic BPH will develop clinical BPH The prevalence of clinical BPH in men ages 55-74 years 5-30% Berry J Urology, 1984, 132(3) 474-9 Bushman, Urol Clin N Am 36 (2009) 403–415

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Overactive Bladder Defined • OAB is diagnosed and defined based on patient history and symptoms: • “Urgency, with or without urge incontinence, usually with frequency and nocturia, in the absence of pathologic or metabolic conditions that might explain these symptoms”

Abrams et al. Urology 2003;61:31-49; Nitti VW, Blaivas JG. In:Wein:Campbell-Walsh Urology. 2007;

OAB Lower Urinary Tract Symptoms (LUTS) Definitions Urgency

Sudden compelling desire to pass urine that is difficult to defer

Increased daytime frequency

8 or more voids in a 24 hour period

Nocturia

1 or more visits to the bathroom during sleeping hours

Urge incontinence

Involuntary leakage accompanied by or immediately preceded by urgency OAB “wet”

Abrams, et al. Urology. 2003; 61:37-49., Cardozo, et al. J Urol. 2005:173;1214-1218.

Causes of OAB 

Myogenic – Involuntary detrusor contractions – Alterations in sensation – Ultrastructural changes in detrusor » Increased electrical coupling, patchy denervation



Neurogenic – Impact on neurologic control » Illness: SCI, Parkinson’s, Dementia, other » Cognitive » loss of central inhibitory controls

– Emergence of new voiding reflexes

Mills et al, Journal of Urology, 163 (2): 646-51 Staskin et al, Urology, 2002; 60 (S1): 1-6

63rd CAFP Annual Scientific Assembly • San Francisco

Overactive Bladder Affects Men and Women of All Ages Men (n=394)

Prevalence (%) 35

Women (n=463)

Overall US prevalence: 16.5% (16.9% in women; 16.0% in men)

30 25 20 15 10 5 0

<25

25-34

35-44

45-54

Age (years)

55-64

64-75

S A T U R D A Y

>75

Stewart, et al. World J Urol. 2003;20:327-336.

National Overactive Bladder Evaluation (NOBLE) Program OAB w/urge incontinence

OAB w/o urge incontinence

Stewart, et al. World J Urol. 2003;20:327-336.

BPH (LUTS) Evaluation



History: Assess for LUTS

– use validated questionnaire: AUA/IPSS » Severity, monitoring

– General including drug, surgical, bowel and neurologic    

Focused PE and Digital rectal exam Dipstick urinalysis PSA in “select patients” Optional: – Uroflow – Post void residual AUA Guideline on Management of Benign Prostatic Hyperplasia (BPH) 2003.

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From AUA Practice Guidelines Committee

BPH: Diagnosis and Treatment Initial Evaluation  History  PSA in selected patients*  DRE and focused physical exam  Urinalysis AUA/IPSS Symptom Index Assessment of Patient Bother Moderate/Severe Symptoms (AUA/IPSS ≥8)

Mild Symptoms (AUA/IPSS ≤7) or No Bothersome Symptoms

Presence of Refractory Retention or Any of the Following Clearly Related to BPH  Persistent gross hematuria  Recurrent UTIs  Bladder stones  Renal insufficiency

Optional Diagnostic Tests  Uroflow  Postvoid residual urine Surgery

Discussion of Treatment Options Patient Chooses Noninvasive Therapy

Patient Chooses Invasive Therapy Optional Diagnostic Tests  Pressure flow  Prostate ultrasound  Urethrocystoscopy

Watchful Waiting

Medical Therapy

Minimally Invasive Therapy

Surgery

DRE = digital rectal exam; IPSS = International Prostate Symptom Score; PSA = prostate specific antigen; UTI = urinary tract infection. *Patients with a 10-year life expectancy for whom knowledge of the presence of prostate cancer would change management or patients for whom the PSA management may change the management of voiding symptoms. AUA Practice Guidelines Committee. J Urol. 2003;170:530–547

AUA Symptom Index with QOL

AUA Guideline on Management of Benign Prostatic Hyperplasia (BPH) 2003.

AUA Symptom Index with QOL Post-void

Irritative Obstructive Irritative Obstructive Obstructive Irritative

AUA Guideline on Management of Benign Prostatic Hyperplasia (BPH) 2003 Abrams P et al. Neurourol Urodyn. 2002;21:167-178

63rd CAFP Annual Scientific Assembly • San Francisco

Daily Bladder Diary 3 days sufficient Available at:

http://kidney.niddk.nih.go v (search “bladder diary”)

S A T U R D A Y

Nygaard and Holcomb. Int Urogynecol J. 2000. 11:15–17. Fink et al. Acta Obstet Gynecol. 1999. 78:254–257; Brown et al. Urology. 2003. 61:802-809; Abrams et al. Urology 2003;61:31-49

What to Consider During Evaluation • • • • • • •

Urinary tract infection Hematuria Urethral stricture Bladder stones Bladder cancer Prostate cancer Other medical conditions causing LUTS • Diabetes • Medications/diuretics

• Post radiation therapy Rosenberg et al. Cleve Clin J Med. 2007 May;74 Suppl 3:S21-9.

Indications for Referral to Urologist  

Hematuria Elevated PSA – Normal cut off vs. velocity – Remember! PSA typically 50% lower when on 5ARI

    



Prostate nodule Failure to respond to treatment Urinary Tract Infection Poor flow Neurologic condition (eg, multiple sclerosis, spinal cord lesions) History of Prostate Cancer treatment (surgery, radiation) Rosenberg et al. Cleve Clin J Med. 2007 May;74 Suppl 3:S21-9.

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How to Approach Use symptoms to gauge if irritative vs. obstructive



– BPH (Obstructive): follow BPH treatment pathway – OAB (Irritative): follow OAB treatment pathway » Consider conservative and lifestyle modifications

– Combined (obstructive and irritative) » Option 1: initiate BPH treatment then reassess if OAB still needed » Option 2: initiate combined BPH and OAB treatment

Decision should be based on symptom type, severity and provider comfort level



BPH

Treatment Options

– Watchful waiting – Medical therapies – Procedural therapies » Minimally invasive therapies (Microwave, RF ablation, Stent) » Surgery (TURP, TUR electrovaporization or laser, TUR incision of prostate, open prostatectomy)



OAB

– Watchful waiting – Behavioral modifications » Weight reduction » Dietary modifications » Urge reduction strategies, bladder retraining,

– Pelvic floor rehabilitative therapy – Medical therapies – Procedures

» Minimally invasive: Botulinum toxin » Neuro-modulation

AUA Guideline on Management of BPH) 2003 Rosenberg et al Cleve Clin J Med. 2007 May;74 Suppl 3:S21-9 Burgio et al. J Am Geriatr Soc. 2000. 48:370-4. Burgio et al. JAMA. 1998;280:1995-2000. Shaker HS et al. J Urol. 1998;159:1516-9 Kuo HC et al. J Urol. 2006;176:641-5

BPH: Pharmacologic Agents  Alpha blocking – – – – – –

Prazosin Terazosin (Hytrin) Doxazosin (Cardura) Tamsulosin (Flomax) Alfuzosin (Uroxatral) Sildosin (Rapaflo)

 5α reductase inhibition – Finasteride (Proscar) – Dutasteride (Avodart)

63rd CAFP Annual Scientific Assembly • San Francisco

Tamsulosin Effects AUA Sx Score

S A T U R D A Y

Lepor H et al Urology. 1998;51:892-900

Tamsulosin Effects on Flow rate

Lepor H et al Urology. 1998;51:892-900

Effect of Finasteride on Prostate Volume

Finasteride

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Effect of Finasteride on BPH Symptoms

Finasteride (N=1437)

Impact of Combined Medical Therapy on Progression of BPH Cumulative incidence of BPH progression Placebo (n=737) Finasteride (n=768) Doxazosin (n=756) Combination (finasteride + doxazosin) (n=786)

Percentage with event

25 20 15

66%

p=0.002

risk reduction (p<0.001)

p<0.001

10 5

p<0.001

0 0

0.5

1.0

1.5 2.0 2.5

3.0 3.5

4.0 4.5

Years from randomization

5.0

5.5

McConnell, N Engl J Med 2003;349(25):2385-2396;

Procedural Management of BPH  Minimally Invasive Techniques: – TUNA (radiofrequency) – TUMT (microwave)

 Transurethral Surgical Techniques: – TURP* – TUIP – Stents

 Open Prostatectomy*

– Retropubic or suprapubic * GOLD STANDARD

63rd CAFP Annual Scientific Assembly • San Francisco

Annual Rates of BPH procedures 1999-2005

S A T U R D A Y

Yu et al, Journal of Urology 2008, 180;241-245

Why is Male OAB Undertreated ? Lack of understanding



– Most treatment aimed at Prostate (BPH) – Few studies showing efficacy of treating male bladders

Concerns in using anticholinergic in male LUTS



– “weakening” of the bladder – Bladder state may represent compensatory effort to deal with obstruction from BPH – Risk of retention

Behavioral Treatment 

Dietary modifications – Avoid over abundance of fluids, avoid night fluids – Eliminate/reduce alcohol, caffeine, bladder irritants

 

Weight reduction Behavioral Modifications

– Urge reduction strategies, bladder retraining, – Pelvic floor rehabilitative therapy

Rosenberg et al. Cleve Clin J Med. 2007 May;74 Suppl 3:S21‐9 Burgio et al. J Am Geriatr Soc. 2000. 48:370‐4. Burgio et al. JAMA. 1998;280:1995‐2000. Subak et al, Journal of Urology, 2005, 174; 190‐195

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Efficacy of Behavioral Intervention for OAB in Men  



Burgio et al 2010 143 men 42-88 years with urgency, frequency (>8) +/- incontinence Randomized clinical trial comparing 8 wks behavioral training vs. oxybutynin ER (All men on alpha blocker) Outcome: compared to drug, behavioral therapy had: – Equal reduction in urinary frequency – Greater reduction in nocturia – Greater patient satisfaction Burgio et al. Journal of Urology, 183 (S1) A #1516, presented at AUA 2010

Efficacy of Behavioral Intervention on OAB with incontinence Urinary Frequency (Baseline)

Urinary Frequency (8 weeks)

Behavioral Training

11.3

9.1

p < .001

Oxybutynin ER (5-30)

11.4

9.6

p <.001

Equivalence analysis confirmed: Behavioral therapy as good as drug therapy in treatment of Male OAB (p=.01) Mean Reduction in Nocturia episodes (p=.04)

Global Perception of Improvement (p=.24)

Patient Satisfaction (p=.04)

Behavioral Training

.72

37%

59%

Oxybutynin ER (5-30)

.32

24%

40%

Burgio et al. Journal of Urology, 183 (S1) A #1516, presented at AUA 2010

Mechanism of Action for Antimuscarinics 

Exact mechanism unknown – Block muscarinic receptors on detrusor, thus reducing frequency and intensity of contractions – Inhibit bladder afferent nerves, reducing detrusor activity and increasing bladder capacity

Abrams P, Andersson KE. BJU Int. 2007 Nov;100(5):987-1006.

63rd CAFP Annual Scientific Assembly • San Francisco

Whats Current in OAB Medical Therapy? 

Immediate Release

– Oxybutynin (Ditropan) – Tolterodine (Detrol) – Trospium (Sanctura) 

Extended Release – – – – –



Darifenacin (Enablex) Fesoterodine (Toviaz) Oxybutynin (Ditropan XL) Solifenacin (Vesicare) Tolterodine (Detrol LA)

S A T U R D A Y

Transdermal Route – Oxybutynin transdermal patch (Oxytrol) – Oxybutynin gel (Gelnique)

Choosing an Antimuscarinic • Formulation (shorter- vs. longer-acting); i.e. extended is better, but more expensive • Titration/ dose escalation • Contra-indications • Route administration; neither is better, just what the patients prefer • Don’t forgot: Formulary issues Chappel et al. Eur Urol. 2005:48:464-70; Novara et al. Eur Urol. 2008; 54:740-63., Basra R, et al. BJUI. 2008. 102:774-779.

Muscarinic Receptor Antagonist as Monotherapy in Male LUTS: Results • • • • • •

Frequency decreased from 9.8 to 6.3/day Nocturia decreased from 4.1 to 2.9 4 men (9%) discontinued due to dry mouth No patients went into urinary retention 1 patient had a urinary tract infection 27 (63%) were potent at baseline, 29 (67%) were potent at 6 months

Kaplan, J Urol. 2005 174(6), 2273-76

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Combined Behavioral and Drug 

Song et al: Bladder Training with/without Tolterodine % whose % whose % whose urgency nocturia frequency score declined Score declined score declined

N=139

Tolterodine \

25.6

56.1

44.8

30.2

65.4

62.2

Combination

33.5

66.3

60.2

Bladder training

– P<0.05 – But subjects only women 

Klutke et al: 357 patients dissatisfied with OAB drug – Added behavioral intervention, plus OAB drug – 91% became at least “a little satisfied” – All bladder diary variables improved (p <0.001) Song et al. J Korean Med Sci. 2006 Dec;21(6):1060-3 Klutke et al, Journal of Urology 2009 181, 2599-2607

Percent of patients

Increased Treatment Benefit With Combination Therapy

P<.001

(n = 222)

(n = 217)

(n = 215)

(n = 225)

Incidence retention (catheter), respectively: 0%, 0.5%, 0%, 0.4% Kaplan SA, et al. JAMA. 2006;296:2319-2328.

Case 1: Roy Roy is a 62 year old male presenting with LUTs. Specifically, he complains of  nocturia 3-4 times/night  weak stream, often feels the need to push and strain  Also with urgency and hesitancy



Symptoms have been present for a few years but have become progressively worse, especially the nocturia which finally drove him to see you now

63rd CAFP Annual Scientific Assembly • San Francisco

Case 1: Roy 1.1b What question is most important? 1. 2. 3. 4.

Has he had blood in urine? Has he had UTI or dysuria? How much fluid does he drink and does he drink at night time? Does he have any other medical problems that might contribute to his urinary problems All of the above

100% 90% 80% 70% 60% 50% 40% 30%

S A T U R D A Y

20% 10% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

Pre

Post

Case 1: Roy Roy’s physical exam:  Majority of exam is noncontributory  GU Exam:

– Normal male genitalia, circumcised – Scrotal exam is normal, no nodules or tenderness – Digital rectal exam: slightly enlarged prostate, no nodules

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Case 1: Roy

1.2b Based on the above information, which of the following should you definitely obtain? 1. Urinalysis and bladder diary 2. Uroflow 3. Cystoscopy 4. Chemistry panel with creatinine

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

0% 0% 0% 0% 0% 0% 0% 0%

Pre

Post

Case 1: Roy Follow-up  His urinalysis is negative  After discussing prostate cancer screening, patient opts for PSA which returns 2.2 (0-4.0).  He does a 2-day diary

– voids 10-12x per day including 4 voids per night. – You note he voids q 1-2 hours at in morning and at night but he seems to last longer in the afternoon.

Case 1: Roy

1.3b What should be included in your recommended treatment plan? 1. Initiate course of alpha blockers 2. Cut back on fluids especially coffee and night time beers 3. Phenylephrine 4. Refer to urologist 5. Both 1 and 2

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

Pre

Post

63rd CAFP Annual Scientific Assembly • San Francisco

Case 2: Hector Hector is a 69 year old male with complaints of:  urgency, frequency q 1 hr, nocturia x 4.  Bothered by urgency and urge leakage

 

– frequently spots underwear when gets urge but can’t get to bathroom in time. – Symptoms more bothersome at night and has leakage at night.

He has been on terazosin 5mg QHS for 5 years, reports force of stream is stable and denies strain void. Hector denies hematuria or dysuria

S A T U R D A Y

Case 2: Hector

2.1b What is most likely causing his urgency and frequency? 1. BPH 2. Overactive bladder 3. Urinary tract infection 4. Prostate cancer

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

0% 0% 0% 0% 0% 0% 0% 0%

Pre

Post

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Case 2: Hector  PMHX: HTN, arthritis  PSHX: Arthoscopic Knee Surgery  Meds: Vicodin, Diclofenac, Enalapril  Soc Hx: Retired, no etoh/tob  PE:

– Abd:soft, nontender, no organomegaly – No palpable suprapubic mass – Normal GU Exam – DRE: prostate 30 gm no nodules

 Labs: PSA 1.6, UA negative

Case 2: Hector 2.2b What do you do first? 1. Address constipation 2. Add anticholinergic 3. Increase terazosin to 10mg QHS 4. DDAVP

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

0% 0% 0% 0% 0% 0% 0% 0%

Pre

Post

Case 2: Hector Three Months Later:  His constipation is better. He is off vicodin.  Urinary symptoms are better but not perfect.

– Nocturia back to x2. Dry at night. – Daytime urgency persists. Still frequent spotting in underwear when gets urge and unable to get to bathroom in time which is bothersome.

63rd CAFP Annual Scientific Assembly • San Francisco

Case 2: Hector 2.3b What is your best option? 1. Continue as is 2. Add anticholinergic 3. Add behavioral modification, pelvic floor exercises 4. Add finasteride

100% 90% 80% 70% 60% 50% 40% 30%

S A T U R D A Y

20% 10% 0%

0% 0% 0% 0% 0% 0% 0% 0%

Pre

Post

In Summary 

Male LUTS can often be attributed to: – BPH – OAB – Combination

 

Don’t underestimate the impact of OAB on men Don’t underestimate the impact that treatment of OAB will have men – Especially conservative measures



Consider staged or combined approaches for the treatment of Male LUTS

Case 1: Roy  

62 year old male presenting with LUTs Specifically, he complains of – nocturia 3-4 times/night – weak stream, often feels the need to push and strain – Also with urgency and hesitancy » he feels he has to rush to bathroom when he gets the urge but then he has to wait until his urination actually starts » Becomes an issue because he is a foreman and sometimes has limited bathroom access

– Symptoms have been present for a few years but have become progressively worse, especially the nocturia which finally drove him to see you now

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Case 1: Question#1 What questions are important? 1) Has he had blood in urine? 2) Has he had UTI or dysuria? 3) How much fluids does he drink and does he drink at night time? 4) Does he have any other medical problems that might contribute to his urinary problems 5) All of the above

Case 1: Question 1 Answer: 5-All of the above 1. Hematuria is important. You will be assessing for this with the urinalysis He has not seen any blood in urine

2. UTI and dysuria are important and will also assess for this with the urinalysis He has not had any dysuria or signs of UTI

3. This is very relevant to presentation. Determining fluid intake, type & timing is key Drinks 4-6 cups of coffee/morning while driving between job sites. He likes 2-3 beers/night after work while watching TV

4. Also important but you can also get from hx 5. All of the Above

Case 1: Medical History     



PMHx: for GERD and hypertension. Meds: esomeprazole & enalapril. PSHx: appendectomy, knee arthroscopy Allergies: NKDA SHx: denies tobacco, (+) ETOH—“few beers per day” FHX: negative for DM, CAD, Negative for Prostate Cancer

63rd CAFP Annual Scientific Assembly • San Francisco

Case 1: Exam  

Majority of exam is non-contributory GU Exam: – Normal male genitalia, circumcised – Scrotal exam is normal, no nodules or tenderness – Digital rectal exam: » slightly enlarged prostate. » No nodules

S A T U R D A Y

Case 1: Question#2 Based on the above information, which of the following should you definitely obtain?



1. 2. 3. 4.

Urinalysis and bladder diary Uroflow Cystoscopy Chemistry panel with creatinine

Case 1: Question #2 Answer: 1 

Answers: 1. YES, definitely 2. NO, this is an option but not definite 3. NO, this is only indicated under certain circumstances (ex: hematuria) 4. NO, this would only be indicated if other circumstances warranted (ex: severe retention with hydronephrosis)

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Case 1 Continued

 



His urinalysis is negative After discussing prostate cancer screening, patient opts for PSA which returns 2.2 (0-4.0). He does a 2 day diary – voids 10-12x per day including 4 voids per night. – You note he voids q 1-2 hours at in morning and at night but he seems to last longer in the afternoon.



What is the most likely problem? 1. 2. 3. 4.

BPH Overactive bladder Excessive fluids (esp. considered bladder irritants) Combination of all above

Case 1: Question #3 

What should be included in your recommended treatment plan? 1. Initiate course of alpha blockers 2. Cut back on fluids especially coffee and night time beers 3. Phenylephrine 4. Refer to urologist 5. Both 1 and 2

Case 1: Question #3 Answer: 5 

What should be included in your recommended treatment plan? 1. 2. 3. 4.

Yes-but this address only part of the problem Yes-but this addresses only part of problem NO! Might make him worse NO, not yet. He should be initiated on first line therapy first. 5. Both 1 and 2

63rd CAFP Annual Scientific Assembly • San Francisco

Case 1: 

Alpha blocker therapy initiated



Returns 3 months later for follow-up

– Tamsulosin .4mg QHS – Force of stream is much improved. – Nocturia improved to 2x/night. – He has cut back on his coffee and beers but admits he still has 2-3 cups of coffee per morning and still has 1-2 beers per night. 

S A T U R D A Y

Now what?

Case 1  

If patient is content, then you’re done If still bothered by urgency and nocturia, then consider additional OAB treatment – Additional fluid modifications – Behavioral therapies – RX: Add antimuscarinic

Case 2: Hector



69 year old male with complaints of: – urgency, frequency q 1 hr, nocturia x 4. – Bothered by urgency and urge leakage » frequently spots underwear when gets urge but can’t get to bathroom in time. » Symptoms more bothersome at night and has leakage at night.

– He has been on terazosin 5mg QHS for 5 years, reports force of stream is stable and denies strain void. – Denies hematuria or dysuria

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Case 2: Hector 

Seems that his symptoms worsened after knee surgery. – You learn he has had problems with chronic constipation that are much worse after knee surgery



Prior to knee surgery, he had: – frequency q 90-120 minutes – rare spot leakage in underwear on way to bathroom. – Had nocturia x2-3 and was dry at night.

Case 2: Question #1 

Question: What is most likely causing his urgency and frequency? 1. 2. 3. 4.

BPH Overactive bladder Urinary tract infection Prostate cancer

Case 2: Question #1 Answer: 2 

Answers 1. NO, patient has stable BPH, doubtful that this is causing new symptoms 2. YES. Seems most likely—he had some OAB symptoms in past but now they seem worse especially with exacerbation of constipation 3. NO, while UTI is possible its not the most likely cause. Plus he has no dysuria or hematuria. This will be confirmed with UA 4. NO, this is unlikely.

63rd CAFP Annual Scientific Assembly • San Francisco

Case 2: PMHX: HTN, arthritis PSHX: Arthoscopic Knee Surgery Meds: Vicodin, Diclofenac, Enalapril Soc Hx: Retired, no etoh/tob PE:

    

– – – –

Abd:soft, nontender, no organomegaly No palpable suprapubic mass Normal GU Exam DRE: prostate 30 gm no nodules

S A T U R D A Y

Labs: PSA 1.6, UA negative



Case 2: Question #2 

Question: What do you want to do first? 1. 2. 3. 4.

Address constipation Add anticholinergic Increase terazosin to 10mg QHS DDAVP

Case 2: Question #2 Answer: 1

1. YES 2. NO, not first option. While it might be an option in future, his progression coincides with worsening constipation and it makes sense to address constipation first. Furthermore, while anticholinergic might help OAB symptoms, his constipation would be at risk of getting worse as side effect of the anticholinergic. 3. NO, this medication is for BPH which is stable now 4. NO, while this medication can be used for “primary nocturia” and enuresis due to disproportionate nocturnal fluid output, this is not the cause of this patient’s problems.

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Case 2: 3 months later:

 

His constipation is better. He is off vicodin. Urinary symptoms are better but not perfect. – Nocturia back to x2. Dry at night. – Daytime urgency persists. Still frequent spotting in underwear when gets urge and unable to get to bathroom in time which is bothersome



What is your best option? 1. 2. 3. 4.

Continue as is Add anticholinergic Add behavioral modification, pelvic floor excercises Add finasteride

Case 2: Question #3 Answer: 3 

Answers: 1. NO, not good option since patient admits he is bothered by urge leakage 2. NO, while this is an option, the patient should be apprised of risk of side effects including constipation which has been problematic for this patient in the past 3. YES, this is best option since able to address OAB symptoms with minimal or no risk of side effects 4. NO, this medication is for BPH which seems stable right now

63rd CAFP Annual Scientific Assembly • San Francisco

Session #4: Saturday, May 14, 12:30-1:45 pm Diabetes Care: A Teach Approach –

How Can We Better Help Mr. Sanchez

Lyman “Bo” Greaves, Jr, MD, FAAFP Medical Director Vista Family Health Center Santa Rosa, CA

S A T U R D A Y

Lenora Lorenzo, DNPc, MSN, FNP/ADM, CDE Team Leader Chronic Disease Program, Department of Veterans Affairs Pacific Island Health Care System, Sparky Matsunaga Center Honolulu, Hawaii Chris Sadler, MA, PA-C, CDE Diabetes and Endocrine Associates La Jolla, CA

Activity Description Our three faculty members will host a lively session will explore how the strength of the team’s interdisciplinary approach to diabetes care can engage the patient in more self-directed management of his/her condition.

Learning Objectives

1. Interpret changing paradigms for health care practice and incorporate them into your practice to improve health outcomes for your patients with diabetes.

2. Work with your practice team to identify, and within three months, implement at least one action plan for team-based diabetes care management.

3. Using the evidence-based tools presented during this session, develop and launch an action plan with your practice team and patients that will engage them in culturally appropriate lifestyle changes and therapeutic alliance.

4. Integrate current treatment guidelines for insulin management of patients with diabetes into your clinical practice.

Faculty Disclosure Dr. Greaves and Ms. Lorenzo declare that in the past 12 months neither they nor members of their immediate families have had financial relationships with the manufacturers of goods or services discussed in this activity. Mr. Sadler declares that during the past 12 months he has consulted and/ or received honoraria from Amylin/Lilly and Amylin.

Professional Advancement | Personal Growth

Faculty Bios Lyman “Bo” Greaves, past CAFP president and chair of our Diabetes Advisory Board, spearheaded the New Directions in Diabetes Care initiative for CAFP/CAFP-F. He received his undergraduate degree from Johns Hopkins University and medical degree from the University of California, Davis. Dr. Greaves is currently medical director of Santa Rosa Community Health Center’s Round Barn Circle campus. He was president of Primary Care Associates, a 23 physician/eight nurse practitioner medical group with five offices in Sonoma County, CA. In 1995, Dr. Greaves developed a prototype of diabetes self-management classes identified through medical group claims data which grew into an independent, community-based health education non-profit county organization. He also developed a diabetes treatment center within St. Joseph Health Foundation that operated out of his medical group. He chaired the Diabetes Coalition of Sonoma County and developed and oversaw a proactive diabetes management program for all patients with diabetes admitted to Santa Rosa Memorial Hospital for Total Joint Replacement Surgery. Leonora L. Lorenzo, APRN, is currently completing her doctorate from the University of Southern Alabama, School of Nursing. She received her Family and Geriatric Nurse Practitioner Master of Science Nursing degrees from the University of Hawai’i, Manoa School of Nursing, and her graduate certificate of gerontology from its School of Public Health. She received her Masters’ in Health Services Administration from Central Michigan University. Ms. Lorenzo is certified by the nurse practitioner boards in both family medicine and gerontology. She is currently the Regional 9 Director of the American Academy of Nurse Practitioners and has been the President of the Hawaii Nurses Association. Chris Sadler graduated from the Stanford University Physician Assistant Certificate Primary Care Associates Program. He is the current President-elect of the American Society of Endocrine Physician Assistants, and past president of the San Diego Society of Diabetes Educators. He is a peer reviewer for the Advance for Physician Assistant Journal, American Association of Physician Assistants and has authored regularly since 1998 on diabetes care and treatment management.

Support This activity is supported by unrestricted educational grants from Lilly, Sanofi Aventis. Merck and Boehringer Ingelheim.

63rd CAFP Annual Scientific Assembly • San Francisco

5/2/2011

Diabetes Care: A Team Approach How We Can Better Help Mr. Sanchez

CAFP’s 63rd Annual Scientific Assembly May 14, 2011

S A T U R D A Y

2011/California Academy of Family Physicians

Faculty Lyman “Bo” Greaves, Jr, MD, FAAFP Medical Director Vista Family Health Center Santa Rosa, CA Lenora Lorenzo, DNPc, MSN, FNP/ADM, CDE Team Leader Chronic Disease Pgm, Dept of Veterans Affairs Pacific Island Health Care System, Sparky Matsunaga Center Honolulu, Hawaii Chris Sadler, MA, PA‐C, CDE Diabetes and Endocrine Associates La Jolla, CA

Faculty Declarations 



The CAFP Committee on Continuing Professional Development is responsible for management and resolution of conflict for any individual who may have influence on content, who have served as faculty, or who may produce CME/CPD content for the CAFP. Dr. Greaves and Ms. Lorenzo declare that in the past 12 months they have nothing to disclose. Mr. Sadler declares that during the past 12 months he has consulted and/or received honoraria from Amylin/Lilly and Amylin.

Professional Advancement | Personal Growth

5/2/2011

Industry Support 



It is the policy of CAFP to ensure independence, balance, objectivity, scientific rigor, and integrity in all of their continuing education activities. This activity is supported by unrestricted educational grants from Lilly, Sanofi Aventis, Boehringer Ingelheim and Merck.

Learning Objectives Based on the information presented, you should be able to: 



Interpret changing paradigms for health care practice and incorporate these paradigms into your practice to improve health outcomes for your patients with diabetes. Work with your practice team to identify, and within three months, implement at least one action plan for team‐based diabetes care management. Using the evidence‐based tools presented during this session, develop and launch an action plan with your practice team and patients that will engage them in culturally appropriate lifestyle changes and therapeutic alliance. Integrate current treatment guidelines for insulin management of patients with diabetes into your clinical practice.

Which one most closely matches your primary care team? 1. 2. 3. 4. 5.

Physician, MA Physician, MA and RN Physician, MA, PA/NP and RN Physician, MA, PA/NP, RN, nutritionist Physician, MA, PA/NP, RN, nutritionist, pharmacist

10 0 of 40

63rd CAFP Annual Scientific Assembly • San Francisco

5/2/2011

Mr. Sanchez 

 



59 yo M with Type2 Diabetes, mild proteinuria, diagnosed and treated for past 2 years BMI 34, BP 140/85, LDL 96, A1C 9 Mild hypertension, hyperlipidemia & obesity Metformin 1000 mg bid, Simvastatin 20 mg qhs, Lisinopril 20 mg qd, and Glipizide 10 mg bid

S A T U R D A Y

The Usual Way 

Patient not engaged in their chronic condition/care



Short, unplanned provider visit, no team

Uninformed, passive patient

Unprepared practice team

Frustrating unproductive interactions

Why do we need a new paradigm of care?

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Difficulties of Provider Communications 



 

Historically trained to deliver knowledge and be directive with patients Patients that are stuck or confrontational are challenging and cause frustration and/or inertia Time pressures of patient visits Payment limitations for patient counseling

Glaseroff, 2009

Who is falling down on the job? 

Is it a provider problem? Sometimes



A patient problem? Sometimes



A system problem? ALWAYS

Mr. Sanchez – Follow Up Visit      



Frustrated; feels “stuck” BMI 32, BP 145/90, PHQ 2 positive Weight remains stable Tries to cut back on eating Activity level low despite joining a gym Average blood sugars for past two months have been 220 Metformin 1000 mg bid, Simvastatin 20 mg qhs, Lisinopril 20 mg qd, and Glipizide 10 mg bid

63rd CAFP Annual Scientific Assembly • San Francisco

5/2/2011

Chronic Care Model

Informed, Activated Patient

Productive Interactions

Prepared, Proactive Practice Team

S A T U R D A Y

Strategies and Tools Team based care Group/Shared Appointments for peer support Motivational Interviewing Action Plans Conversation Map Self Management Education ‐ Internet: Diabetes dictionary, BMI calculator, exercise guide, glucose tracker, etc. Therapeutic options

What is Motivational Interviewing? 

   

A patient‐centered, goal‐oriented method for enhancing intrinsic motivation to change by exploring and resolving ambivalence Emerged in addictions field in the 1980s Effective across cultural boundaries Transcends traditional patient education Over 300 clinical trials Primary care Public health Health Promotion Dyslipidemia

HIV Smoking Diet Hypertension

Diabetes Adherence Obesity Exercise

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5/2/2011

The Spirit of MI Empathetic Evocative

Collaborative Goal‐oriented Supporting autonomy

 Authoritarian  Educational  Confrontational

Behavioral change action plans 



You cannot make someone do something they do not want to do! Action plan = agreement

Before trying to make an agreement,  How important is the change to the person making it?  How confident do they feel about the change?

The “Action Plan” Intervention 1.

Don’t tell patients what to do

Negotiate what changes to focus on blending your expertise and patients’ desires

Focus on 1 or 2 concrete actions to start Not attitudes, numbers, or actions to stop Not “lose 5 pounds in 2 weeks” Instead… “Walk briskly 20 minutes 3 x/ week, Monday, Wednesday and Friday after lunch”

63rd CAFP Annual Scientific Assembly • San Francisco

5/2/2011

Sample of action plan My Action Plan Date_______ 1 _____(Name)_______________ and ___(my clinician)______________ have agreed to improve my health, I will: ___Work on something bothering me

___Improve my food choices

___Stay more physically active

___Reduce my stress

___Take my medications

___Cut down on smoking

Here is what I can do: _______________________________________ How much? _________ When?____________ How Often?___________

S A T U R D A Y

This is how sure I am that I will be able to do this (circle a number) Not sure 1

Very sure 3

Primary Care Teams Teams: a group of diverse clinicians who participate in, and communicate with each other regularly about the care of a defined group (panel) of patients.

Teamlet Model Primary care visit Family Community

Patient

Clinician

Shared Decision‐making

Health Coach

Team huddle

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“Health Coach” Core Skills     

Setting agendas Discussing ABCs of diabetes care Medication reconciliation Closing the loop Behavioral change action plans

Filling the Health Coach Role 

How it works in three different practices:   



Lyman “Bo” Greaves, Jr, MD, FAAFP Lenora Lorenzo, DNPc, MSN, APRN‐Rx Chris Sadler, MA, PA‐C, CDE

How else can it work?  

Peer Health Coaches Family Members

Components of self‐management support     

 

Provide information Intensive skills training (disease specific) Encouraging healthy behavior change Teach patients problem‐solving skills Assisting patients with psychosocial issues and the emotional impact of having a chronic condition Provide ongoing and regular follow‐up Encourage and train patients to become active participants in their care

63rd CAFP Annual Scientific Assembly • San Francisco

5/2/2011

Self Management and Self Management Support … Supporting Patients Where They Are

People like me

Family and friends

Communication Health education

Community, including workplace

Health system

S A T U R D A Y

Follow up Team Care

The most common barriers to beginning insulin therapy include         

Patient fear and resistance; Clinician resistance; Association of needles and injections with pain; Fear of complications (eg, amputations or kidney failure); Weight gain; Inconvenience; Time commitment required; Lack of education; and Cost

Meece J. Dispelling myths and removing barriers about insulin in type 2 diabetes. Diabetes Educ. 2006;32(suppl 1):9s‐18s

Dispelling Fears    

Team’s positive attitude toward insulin Not Painful! Devices are user friendly Children can administer

“It’s not a tattoo. I mistook a Bic for an Insulin Pen” 2004 Diabetes Health

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Benefits of Insulin Dosing Regimens 

One Injection  Intermediate‐acting or long‐acting

insulin analog at bedtime  Premixed insulin before dinner 

Two injections  Breakfast and dinner injections of premixed insulin  Breakfast and dinner: short‐acting or rapid‐acting plus

NPH or long‐acting insulin analog

Chan JL, Abrahamson MJ. Pharmacological management of type 2 diabetes mellitus: rationals for rational use of insulin. Mayo Clin Proc. 2003;78:459‐467 and Owens DR, Zinman B, Bolli GB. Insulins today and beyond. Lancet. 2001;358:739‐746

Treat to Target Self‐monitored FPG (mg/dL) From Titration: Preceding 2 Days With no Episodes Increase in of Severe Hypoglycemia or PG ≤ 72 Insulin Dose mg/dL (IU/d) 100‐120 mg/dL 2 4 120‐140 mg/dL 6 140‐180 mg/dL 8 ≥ 180 mg/dL FPG = fasting plasma glucose; PG = prandial glucose Riddle M, Rosenstock J, Gerich J; Insulin Glargine 4002 Study Investigators. The treat‐to‐target trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care. 2003;26:3080‐3086

AACE/ACE Diabetes Algorithm A1C > 9.0% Drug Naive

Under Treatment

Symptoms No Symptoms GLP‐1 or DPP41

INSULIN + Other Agent(s)3

MET +

TZD2 GLP‐1 or DPP41

+ SU4 + TZD2

INSULIN + Other Agent(s)3

1 DPP4 if I PPG and I FPG or GLP‐1 if II PPG 2

TZD if metabolic syndrome and/or nonalcoholic fatty liver disease (NAFLD)

3 (a) Discontinue insulin secretagogue with multidose insulin (b) Can use pramlintide with prandial insulin 4

Decrease secretagogue by 50% when added to GLP‐1 or DPP‐4

Used with permission from American Association of Clinical Endocrinologists. AACE/ACE Diabetes Algorithm for Glycemic Control. www.aace.com/pub/pdf/GlycemicControlAlgorithmPPT.pdf

63rd CAFP Annual Scientific Assembly • San Francisco

5/2/2011

Summary 



Engage and partner with patients in chronic illness care‐ they are in charge! Use motivational interviewing skills and concrete tools like action plans ‐ they can work. Build primary practice teams that can support patients in self management‐ you cannot do this alone for a full panel of patients. Start insulin sooner (especially if AC1 is consistently greater than 9)

S A T U R D A Y

Thank You!

Questions?

Resources 



The Center of Excellence in Primary Care website: http://familymedicine.medschool.ucsf.edu/cepc/ Improving Primary Care. Strategies and tools for a better practice. Thomas Bodenheimer and Kevin Grumbach. 2007. [Chapters on Improving Primary Care for Patients with Chronic Illness. Self‐Management Support for People with Chronic Illness. Health Care Teams in Primary Care.] Look out for article in Family Practice Management: “Health coaching for patients with chronic conditions” by Bennett et al. Accepted for publication. American Association of Clinical Endocrinologists. AACE/ACE Diabetes Algorithm for Glycemic Control. http://www.aace.com/pub/pdf/GlycemicControlAlgorithmPP T.pdf

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Engagement 

A connection which continues throughout the encounter  Person to person  Professionally, as partners



Tools for Engagement  Introduce yourself  Greet your patient  Welcome your patient  Maintain eye contact

MI Technique: Menu of Options 



Objective: To avoid the ‘Yeah‐but’ dance that typically happens when advice is given. To provide the patient with tips and techniques that have helped other but to put them into the driver’s seat to ‘own’ the solution. Example: “So Mr. Sanchez, you do want to get these blood sugars under control but you just keep forgetting to take your medication. Would you be interested in hearing about some tips that have helped other patients?” After patient gives consent, the provider presents 3‐4 brief ideas. Then says: “Of these options or another that you can think of, which one(s) do you think might be helpful for you?”

MI Technique: Rolling with Resistance by Using Reflective Listening/Empathy 



Objectives: To establish rapport and avoid resistance by demonstrating your understanding of the patient’s situation. To avoid pushing against and magnifying the resistance. Example: “It’s not easy making all these changes. You’re thinking that you might not want to take the medication anymore. ” Follow‐up after giving patient a chance to respond: “On the other hand, you said that you know that these numbers [A1Cs and blood glucose levels] put you at risk.”

63rd CAFP Annual Scientific Assembly • San Francisco

5/2/2011

Pre‐visit and Visit by Health Coach 



Pre‐visit  Asking about the patient’s agenda for the visit  Medication reconciliation  Review chronic care labs Visit  Can sit in on visit between provider and patient  May interpret if appropriate  Can help document or fill out forms

S A T U R D A Y

Post‐visit by Health Coach  

  



Checks patient understanding: “Closing the loop” Makes sure patient agrees with decisions made in visit (patients don’t participate in decisions 91% of the time) Does behavior‐change goal setting/action plans Helps patients navigate system Sees if patient has any issues/concerns; health coach listens Clinician may “pop in” if coach has questions

Between‐visit by Health Coach 



Coach calls patients between visits to see how they are doing with taking their meds, behavior‐change action plans, how they are feeling Often difficult for patients to call their clinician; they can call the coach if there is a problem, providing between‐visit easy access Coach documents phone contact and checks with clinician if needed

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SAMs Group #1: Saturday, May 14, 12:30-5:30 pm Cerebrovascular Disease SAM

Cheri Olson, MD Assistant Professor, Family Medicine Mayo Clinic College of Medicine LaCrosse, WI

Activity Description Using a question-and-answer interactive format, the registrants for this session will complete Part 1 of the Cerebrovascular SAMs, and will have the opportunity to begin Part 2 patient simulation.

Measures of success include:

1. 80% of questions correctly answered within each competency area

3. Upon successful completion, progression to the simulation component (Part B)

2. 80% successful completion rate for questions overall

Measures of success (demonstration of skills) include: Carrying out at least 50% of the performance actions/interventions, as specified by the above guidelines, in taking a history, performing a physical examination, performing a laboratory evaluation, and managing care for a cerebrovascular disease case, during the simulated clinical encounter.

Learning Objectives Upon completion of Part A, the physician will be able to demonstrate knowledge in:

1. Pathophysiology

3. Acute management

2. Diagnosis

4. Chronic management 5. Rehabilitation 6. Prevention

Upon completion of Part B, the physician will be able to demonstrate skill in:

7. Taking a history for a cerebrovascular disease case

9. Performing a laboratory evaluation for a cerebrovascular disease case

8. Performing a physical examination for a cerebrovascular disease case 10. Managing care for a cerebrovascular disease case

63rd CAFP Annual Scientific Assembly â&#x20AC;˘ San Francisco

Faculty Disclosure Dr. Olson declares that in the past 12 months neither she nor members of her immediate family have had financial relationships with the manufacturers of goods or services discussed in this activity.

Faculty Bio Cheri L. Olson, MD, received her medical degree from the University of Minnesota School of Medicine. She is assistant professor at the Mayo Clinical College of Medicine, associate director of the LaCrosse-Mayo Family Practice Residency Program, and CME Director of Francisco Skemp Healthcare. Dr. Olson was selected Family Physician Educator of the Year at the Wisconsin Academy of Family Physicians, and won the “Dr. Frank” Award for Excellence in Residency Teaching. She is founder and chair of the Seven River Sudden Cardiac Arrest Association, is current Medical Director of the Interstate Postgraduate Medical Association, and serves on the Board of Director of WORLD Services of La Crosse and La Crescent, Minnesota Healthy Community Partnerships. Dr. Olson has authored and lectured on pediatrics, patient safety, preventive, and women’s health issues.

S A T U R D A Y

Handout materials will be provided to registrants in the Theater Conference Room.

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Session 5: Saturday, May 14, 1:45-2:45 pm

Prescription Drug Abuse and Dependence

Carol Havens, MD Director, Clinical Education Kaiser Permanente, Northern California Staff physician, Chemical Dependency and Recovery Program Kaiser Permanente, Sacramento

Activity Description Dr. Havens will lead the audience through an interactive look at prescription drug abuse and dependence, including a discussion of the competencies need for safe and effective prescribing.

Learning Objectives

1. Complete a self-assessment of current knowledge of pain management and opioid guidelines.

2. Use assessment tools for screening, risk stratification, and monitoring of patients with chronic pain being considered for opioid therapy or already receiving opioid therapy. 3. Select and sequence appropriate opioid regimens by employing “safe prescribing” practices, based on current guidelines.

Disclosure Dr. Havens declares that in the past 12 months neither she nor her spouse have had financial relationships with the manufacturers of goods or services discussed in this activity.

Faculty Bio: Carl Havens, MD, is CAFP’s incoming President for 2011. Dr. Havens received an undergraduate degree in Medical Technology from Michigan State University and her medical degree from the University of Arizona. She completed her residency training at the University of California, DavisSacramento Medical Center Family Practice Residency Program. Dr. Havens is board certified in family medicine and addiction medicine. She is Director of Clinical Education at the Kaiser Permanente Medical Care Program, Northern California Region, and is a staff physician of Chemical Dependency and Recovery Program at Kaiser Permanente. Over the course of her career, Dr. Havens has held leadership positions as medical director at Womankind Health Clinic, assistant clinical professor with the Department of Family Practice at UC Davis School of Medicine, and assistant director at the Regional Staff Education in Oakland. She is a member of AAFP, CAFP, American Medical Association (AMA), California Medical Association, Sacramento-El Dorado County Medical Society, and Alliance for Continuing Medical Education. Dr. Havens holds multiple committee appointments as the Chair of the Planning Committee for the Annual Northern California Kaiser Permanente Family Practice Symposium, member of the CAFP’s Committee on Continuing Professional Development, chair of the National Permanente Internet CME Committee, and member of Board of Trustees, Audio-Digest Foundation. Dr. Havens has been published in more than 15 peer-reviewed journals and other publications, and is the recipient of CAFP Foundation’s 2009 Barbara Harris Award for Educational Excellence.

63rd CAFP Annual Scientific Assembly • San Francisco

PRESCRIPTION DRUG ABUSE/DEPENDENCE

S A T U R D A Y

CAROL HAVENS, MD CAFP ASA MAY 14, 2011

FACULTY DISCLOSURE  The CAFP Committee on Continuing Professional Development is responsible for management and resolution of conflict for any individual who may have influence on content, who have served as faculty, or who may produce CME/CPD content for the CAFP.  Neither I nor my spouse have financial relationships with the manufacturers of goods or services discussed.

OBJECTIVES 1. Identify red flags for opioid abuse/dependence 2. Differentiate between opioid dependence and addiction 3. Appropriately manage physiologic dependence and addiction

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THE ADDICTION EPIDEMIC OF OUR TIME While Hollywood continues to lose stars to prescription drug abuse, it is not just celebrities who are dealing with these addictions.

More than 50 million Americans … about 1 in 6 … have admitted to abusing prescription drugs, according to a CBS Evening News report.

VICODIN®  Rap star Eminem has a Vicodin® tattoo on his arm  A picture of a Vicodin® tablet was on one of his previous CDs  The current CD cover is a collage of pills as his face

AFTERMATH ©

INCIDENCE  20% have used for non-medical reasons  3% on long term opioids for non cancer pain  Among 12th graders, prescription drugs are second only to marijuana  8% have used hydrocodone  5% have used oxycodone

63rd CAFP Annual Scientific Assembly • San Francisco

TREND IN PRESCRIPTION DRUG ABUSE 

Prescription pain relievers had the largest number of new abusers (2.1 million)1



Non-medical use of prescription drugs (1.7 million) ranks second only to marijuana (3.9 million) as the most prevalent category of drug abuse1



31% of emergency department visits associated with non-medical use of pharmaceuticals2



In 2008, 6.2 million people aged 12 or older were current illicit users of prescription drugs



2007 DAWN estimates that 855,838 ED visits involved non-medical use of prescription, over the counter or dietary supplements2

S A T U R D A Y

1) 2007 National Survey on Drug Use and Health (NSDUH) published Sept 2005 by the Dept of HHS / Substance Abuse and Mental Health Services Administration (SAMHSA) 2) 2007 DAWN (Drug Abuse Warning Network) Report published May 2006 3) SAMHSA ‘Results from the 2008 National Survey on Drug Use and Health: National Findings”

In 2008, 8.6 Million Americans Age 12+ Used A Prescription Drug For Non-medical Purposes In Past Month 0.2 million



Sedatives

0.9 million



Stimulants

1.8 million



Anti-Anxiety Medication

4.7 million



Narcotic Pain Relievers

2008 National Survey on Drug Use and Health (NSDUH), published by Dept of HHS / Substance Abuse and Mental Health Services Administration (SAMHSA)

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION “SAMHSA” 2008 NATIONAL SURVEY ON DRUG USE AND HEALTH

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PRESCRIPTION DRUG ABUSE INCREASES WITH AGE

National Survey of American Attitudes on Substance Abuse XIII: Teens and Parents, CASA August 2008

INCIDENCE  ED visits increased by 111% from 2004-2008  Drug OD second leading cause of accidental death (42% opioids)  Substance abuse treatment admissions increased from 2.2% in 1998 to 9.8% in 2008

PHYSICIANS  Rates of drug and alcohol abuse similar to general population 10-15%  Rates of opioid abuse higher  Anesthesiology, ER, psych highest rates  Pediatrics, pathology, radiology, OB/GYN lowest

63rd CAFP Annual Scientific Assembly • San Francisco

WHERE ARE THEY GETTING IT? 

Majority got from friends/relatives, most for free



Prescriptions, mostly from one physician



Internet



Theft-including altering prescriptions, stealing prescriptions or calling in fake prescriptions



Doctor shopping



Diversion from pharmacy



Inappropriate prescribing

S A T U R D A Y

BLOG WEB SITES AND SOCIAL NETWORKING

CRAIG’S LIST

Oxycodone

Adderall

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PRICES OF RX MEDICATIONS

WHAT ARE THEY USING?  Hydrocodone  Oxycodone  Cough syrup  Morphine

HYDROCODONE QUICK FACTS Most commonly diverted and abused in US

Most frequently prescribed medication in the US According to the 2005 International Narcotics Control Board (INCB) Report, the United States manufactures nearly 100% of the total Hydrocodone manufactured worldwide. It also accounts for 99% of the world consumption.*

* 2005 INCB report

63rd CAFP Annual Scientific Assembly • San Francisco

OLD OC VS NEW OP Old Formulation

New Formulation

New Pill When you try to Crush Milled tablet Mix with water

S A T U R D A Y

COUGH SYRUP “COCKTAILS” ON THE RISE Mixes of codeine-containing cough medicine with soft drinks or sports drinks: • Users typically mix an ounce of the medicine with a sports drink, Sprite or Big Red, then plop in a Jolly Rancher candy and pour the mixture over ice • May add Vodka to mixture • How to videos on You Tube

MY SPACE RECIPE

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WHAT ARE THE STREET NAMES?         

Texas Tea Texas Oil

Sizzurp Jolly Rancher Lean Purple Drank Purple Stuff Purple Jelly Barre

RISK FACTORS  Personal history of substance abuse  Family history of substance abuse  Chronic use of opioids  Psychiatric diagnosis • Physical or emotional trauma such as veterans or DV

RED FLAGS FOR PATIENTS ON OPIOIDS  Early refills

 Lost prescriptions

 Multiple unsanctioned increases in dosage  Prescriptions from multiple providers  Abuse of other drugs

 Refusal of diagnostic workup or consultation  Multiple medication sensitivities

63rd CAFP Annual Scientific Assembly • San Francisco

MORE RED FLAGS       

Feigns Illness: Complaints of back/neck pain, headaches, cough without other symptoms Has legitimate medical or dental issues but does not get appropriate treatment Self-inflicted injury Ask for specific medication / non-generic Cancels follow-up appointments Won’t fill prescriptions for non-controlled substances such as antibiotics Emergency Room visits

S A T U R D A Y

CALIFORNIA OFFICE OF ATTORNEY GENERAL: CURES REPORT Run a CURES “Patient Activity Report” on your suspected patient. This can be accessed by filling out a form manually. Sign up for online access to cures: http://ag.ca.gov/bne/cures.php

CURES “PATIENT ACTIVITY REPORT”

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DEPENDENCE VS. ADDICTION Dependence-physiologic response to medication-not unique to opioids Addiction-maladaptive behavior related to drug use

SUBSTANCE ABUSE One or more of following in 12 months: • Failure to fulfill major role obligations at work, school or home • Use in hazardous situations • Recurrent legal problems • Continued use despite adverse consequences

ADDICTION Three or more in 12 months • Tolerance • Withdrawal • Taking more or for longer than intended • Persistent desire or inability to control use • Time spent in related activities • Loss of other activities • Continued use despite consequences

100

63rd CAFP Annual Scientific Assembly • San Francisco

MANAGEMENT: DEPENDENCE • Taper by no more than 10%/day each week • Detox per addiction protocol

S A T U R D A Y

MANAGEMENT: ADDICTION Detox • Symptomatic management • Opioid taper (tramadol) Relapse prevention Maintenance • Buprenorphine • Methadone-only in licensed clinics

WITHDRAWAL  Uncomfortable, not life-threatening  GI-nausea, vomiting, diarrhea, abdominal cramps  Autonomic-sweats, chills, “bugs under skin,” restless legs, electric shocks  Psychiatric-anxiety, depression, insomnia  Pain  Duration depends on drug

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101

SYMPTOMATIC CARE  Pain (tramadol, NSAIDS)  Nausea (promethazine)  Diarrhea (loperamide)  Abdominal cramps (dicyclomine)  Sweats, chills, autonomic symptoms (clonidine)  Insomnia (trazodone, benzos carefully)

RELAPSE PREVENTION  12 step programs  Formal treatment (various types)  High risk of relapse if no treatment other than detox

RECOMMENDATIONS

102



High index of suspicion



Appropriate workup including complete history and PE-get old records if possible



Think very carefully before starting opioids especially in adolescents



Use pain contracts with chronic opioids



Advise locking up drugs



Drug test, CURES



Refer for addiction

63rd CAFP Annual Scientific Assembly • San Francisco

PRESCRIPTION PAD SECURITY  Do not leave prescription pads in your white coat pocket when you are done for the day  Do not leave them on your desk unattended

 Keep all prescription pads (current pad “when not in use” and unused pads) stored in a secured locked cabinet or drawer

S A T U R D A Y

 Inventory and keep a log of your pads

RESOURCES  CSAT TIPs  (45-detoxification and substance abuse treatment)  Websites  Ncadi.samhsa.gov  Csam-asam.org  Pmp.doj.ca.gov  Drugabuse.gov (NIDA)

THANKS!

Questions?

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Session #6: Saturday, May 14, 3:15-4:15 pm Breaking Down the Wall:

Tackling Barriers in Depression Treatment

Thomas Bent, MD Medical Director and CEO Laguna Beach Community Clinic Laguna Beach, CA

Activity Description Using a talk radio format, Dr. Bent will guide participants on how to engage patients to understand the barriers they face in treatment and develop self-efficacy to care for themselves and become more compliance about treatment.

Learning Objectives

1. Identify and diagnose patients with depression, while paying particular attention to patient somatic symptoms 2. Engage in discussion with patients to better understand the barriers they face in treatment and develop a mutually-agreeable action plan

3. Effectively treat patients with depression to a goal of achieving and maintaining remission 4. Recognize the special issues and barriers to care in unique populations

Disclosure Tom Bent, MD declares that in the past 12 months neither he nor members of his immediate family have had financial relationships with the manufacturers of goods or services discussed in this activity.

Faculty Bio Thomas C. Bent, MD, completed his medical education at the Autonomous University of Guadelajara and his postgraduate training at the University of California, Irvine Medical Center in the Departments of Family Medicine and Physical Medicine and Rehabilitation. He is a clinical professor of family medicine at UCI and received the Kammerman Award for Distinguished Practice and Teaching in Family Medicine. He has been selected as “Outstanding Primary Care Physician” and “Distinguished Alumnus” at UCI. Dr. Bent was CAFP President in 2009-2010. He has also authored on a diversity of topics for CAFP and participated in many AAFP and CAFP committees.

Support This session is supported by an unrestricted educational grant from Pfizer.

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63rd CAFP Annual Scientific Assembly • San Francisco

4/25/2011

Breaking Down the Walls: Barriers to Care for Depression Thomas C. Bent, MD FAAFP May 14, 2011

S A T U R D A Y

Faculty Disclosure • The CAFP Committee on Continuing Professional Development is responsible for management and resolution of conflict for any individual who may have influence on content, who have served as faculty, or who may produce CME/CPD content for the CAFP. • Dr. Bent declares that neither nor his spouse have financial relationships with the manufacturers of goods or services discussed, or corporate supporters of this event.

Educational Objectives • By discussing barriers in our own practice, we will improve our ability to recognize and diagnose depression in a busy FP practice. • Explore the efficacy of psychotherapy in depression, and develop action plans to include psychotherapy into practice. • Actively engage patients with depression using the basic principles of cognitive behavioral therapy to augment pharmacological treatment options.

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4/25/2011

Depression: The Cost to Society • • • •

Major health problem in the US 18 million office visits/yr 100 million prescriptions/yr “Clinical paradox” – only 1 of 3 patient accurately diagnosed • Economic costs: $44 billion/yr

Dr. Huda Akil, President of the Society for Neuroscience from FY2004 Appropriations Testimony to the US Senate Appropriations Subcommittee on Veterans Affairs, Housing and Urban Development and Independent Agencies: 4/2003.

Depression: Incidence/Prevalence • Lifetime prevalence: 17% • 8 million cases of major depressive disorder per year • Antidepressants are among the most commonly prescribed medications in United States .

Psychology Facts & Figures, California Psychological Assoc., 2004, http://www.calpsychlink.org/resources/psychfactsfigures.htm.

Depression: Risk Factors • • • •

Age: peak age of onset 20‐40 yrs Gender: female 2 X Family history: 1.5 to 3 X Marital status: divorced, separated, widowed, married vs unmarried?

Stephen Stahl, M.D., Ph.D. Essential Psychopharmacology of Depression and Bipolar Disorder, Cambridge University Press, 2000:6

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63rd CAFP Annual Scientific Assembly • San Francisco

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Depression: Risk Factors • Personal history of depression 1 episode – 50% relapse 2 episodes – 75% 3 episodes – 90% • Postpartum: up to 1 in 10 • Chronic medical illness

S A T U R D A Y

Stephen Stahl. Essential Psychopharmacology of Depression and Bipolar Disorder. Cambridge, MA: Cambridge University Press; 2000:16.

Depression: DSM‐IV 5 of 9 Required • • • • • • • • •

Depressed mood* Loss of interest or pleasure* Change in sleep Change in appetite/weight Low energy/fatigue Psychomotor agitation/slowing Low self‐esteem or guilt Poor concentration Thoughts of suicide or death

Depression: A SAD FACE(S) A ‐

Appetite

S ‐ A ‐ D ‐

Sleep Anhedonia Depressed mood

F ‐ A ‐ C ‐ E ‐ S ‐

Fatigue Agitation Concentration Esteem Suicidal Montano B. J Clin Psychiatry. 1994;55(12):18‐33.

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What Patients Say: • “Could you prescribe some vitamins for me?” • “By the way, could you give me something to help me sleep?” • “How ‘bout that erectile dysfunction medication?” • “I need something for stress”

S A T U R D A Y

What Patients Say: • “I think I have hypoglycemia.” (or Systemic Candida, CFIDS, etc) • “I want you to test me for everything” • “I don’t know what’s wrong with me”

Depression: Screening U.S. Preventive Services Task Force Screening instruments:    

Beck Depression Inventory Zung Self‐Depression Scale Prime MD Patient Health Questionnaire Center for Epidemiologic Study Depression Screen (CES)

Pignone MP et al. Ann Intern Med. 2002;136:765‐776.

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Depression: Screening U.S. Preventive Services Task Force

2 questions to ask: 1) Over the past 2 weeks have you ever felt down, depressed, or hopeless? 2) Over the past 2 weeks, have you felt little pleasure or interest in doing things? Sensitivity 96%

Specificity 57%

Pignone MP et al. Ann Intern Med. 2002;136:765‐776.

Questions to Ask • “How are things at work?” • “How are things at home?” • “We all have stress in our lives. Has your stress level increased lately?” • “How are you handling it?”

Questions to Ask • • • •

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“How much are you drinking?” “Is that more than usual?” “What medicines are you taking?” “What OTCs and herbal remedies are you taking?”

63rd CAFP Annual Scientific Assembly • San Francisco

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Questions to Ask • “Has anyone in your family suffered emotional or stress‐related problems?” • “Have you had problems like this before?” • “Who do you have to talk to?”

S A T U R D A Y

Suicide Risk Factors • • • • •

Hopelessness Caucasian race Male Advanced age Living alone

Sadock et al. Synopsis of Psychiatry. Philadelphia, PA: Lippincott Williams and Wilkins; 2003:913‐4.

Suicide Risk Factors • • • • •

Prior suicide attempts Substance abuse General medical illness Psychosis Ways and means

Sadock et al. Synopsis of Psychiatry. Philadelphia, PA: Lippincott Williams and Wilkins; 2003:913‐4.

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Depression: R/O Bipolar • “Have you ever had 4 continuous days when you were feeling so good, high, or ‘hyper’ that other people thought you were not your normal self, or you got into trouble?” • “Have you experienced 4 continuous days that you were so irritable that you found yourself shouting at people or starting fights or arguments?”

Wisner et al. N Engl J Med. 2002;347:194.

Natural History of Untreated Depression Normal mood Symptoms

65% Recovery

20‐25% Dysthymia

Syndrome

5‐10% stay depressed Depression 2 year

American Psychiatric Association practice guideline for the treatment of patients with major depressive disorder: Am J Psychiatry. 2000;157(4 Suppl):1‐45. National Guideline Clearinghouse: http://www.guideline.gov

Barriers to Treatment Denial Embarrassment Viewed as weakness of character

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Major depression is a medical condition that can be successfully treated.

S A T U R D A Y

Psychotherapy Multicenter trial, 12 academic centers, 519 subjects with chronic depression • Cognitive‐behavioral Rx: 52% response • Nefazodone alone: 55% response • Combined treatment: 85% response

Keller et al. N Engl J Med. 2000;342:1462.

Psychotherapy PROS: • No side effects • Proven efficacy • Enduring nature of therapeutic gain

CONS: • Time‐consuming • May take longer to work • Reimbursement

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Evidence‐Based Recommendation: Psychotherapy may be as effective as medication in the treatment of mild to moderate depression and should be considered, especially in patients who prefer to avoid medication.

National Guideline Clearinghouse. Available at: www.guideline.gov

A Treatment Model for Depression: The Non‐Rx Rx • • • •

Exercise (as medically safe) Social support Activity Read The Feeling Good Handbook by David Burns, MD • Regular psychotherapy with a physician or mental health professional Websites: http://beckinstitute.org and http://cognitivetherapynyc.com

Etiology of Emotion • Belief

• He makes me mad (or sad) • That scares me (or makes me feel guilty)

• Truth

• “Nothing ‘tis good or bad … thinking makes it so.” ‐‐ Shakespeare

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The Process

S A T U R D A Y

Four Basic Irrational Beliefs Perfection Love/Approval Fairness Punishment

….. ….. ….. …..

Failure Worthlessness Whine/Pout/Tantrum Depression/Anger

Perceptions of Four Major Negative Emotions Sadness Anger Fear Guilt

= Perception of loss = Perception of violation = Perception of threat = Perception of responsibility

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Brief Effective Techniques Serenity Pledge/Prayer I promise … to work as hard as I can to change the things I can change; I promise …t o accept the things I cannot change; I promise … to work on the wisdom to know the difference.

Two‐Column Thought Record What if everyone hates my talk

That’s never happened in 20 yrs of presentations

I’ll never be invited back

If it does today, it’s unpleasant but not catastrophic

I’ll be a failure

My self‐worth doesn’t depend upon my performance/success

0‐100% Mood/Event Rating 1. I’m 90% mad about getting this ticket 2. In the big picture, the ticket is worth a 2% rating.

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Tantrum Time Schedule time (deliberately) to whine/pout/moan (safely), then release and go on.

S A T U R D A Y

Mood Rating Rate mood regularly to assess progress +10 Best +9 +8 +7 +6 +5 +4 +3 +2 +1 0 ‐1 ‐2 ‐3 ‐4 ‐5 ‐6 ‐7 ‐8 ‐9

‐10 Worst

Addictive vs preferential words • Monitor/reduce/eliminate “Addictive” thinking; must, should, have to, always, never (especially combinations) • Replace with “preferential” thinking: better if…, prefer that…, it’d be nice if…, be great if…

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Failure of CBT • Unrealistic expectations of immediate total relief • Patients wait until they “feel like” working at therapy • Quick initial relief – stop treatment or practice

Results: “Of course, I am anxious for all of my symptoms to go away, but this is the best I have felt in the past 5 months! I was feeling suicidal before I came to you. All melodrama aside, I am certain you saved my life. Thank you so very, very much…” – Karen L.

At this point, how confident are you in your ability to understand and utilize the basic principles of cognitive behavioral therapy? 1. 2. 3. 4. 5. 6. 7.

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Very Uncertain Fairly Uncertain Slightly Uncertain Neutral Slightly Confident Fairly Confident Very Confident

63rd CAFP Annual Scientific Assembly • San Francisco

Session #7: Saturday, May 14, 4:15-5:30 pm

Circadian Rhythm Disorders: Asking the Right Questions

Larry Culpepper, MD Professor, Department of Family Medicine Boston University School of Medicine Chief, Department of Medicine Boston Medical Center Jeffrey Luther, MD Director Long Beach Memorial Medical Center Family Medicine Residency Program Long Beach, CA

Activity Description This session features two family physicians presenting evidence-based approaches to sleep-history taking. Special emphasis will be placed on recognizing circadian rhythm disturbances, in particular those associated with shift work.

Learning Objectives

1. Recognize excessive sleepiness and mood and performance impairments as surrogate markers for sleep/wake, medical and psychiatric disorders commonly encountered by family and primary care physicians.

2. Integrate findings from a sleep history to help formulate a differential diagnosis and therapeutic plan for primary care patients with common sleep/wake complaints and medical and psychiatric disorders. 3. Treat sleep/wake complaints and their underlying etiologies to improve patient function across quality of life, cognitive, and mood-related dimensions.

Faculty Disclosures Dr. Lutehr declares that in the past 12 months neither he nor members of his immediate family have had financial relationships with the manufacturers of goods or services discussed in this activity. Dr. Culpepper declares he has served as a consultant/advisor related to mood disorders, sleep, immunizations and menopause topics for AstraZeneca Pharmaceuticals LP; Labopharm; Pfizer Inc., Trovis Pharmaceuticals, LLC. He has also made presentations regarding a federally-funded study of methods to reduce hospital readmissions (with no mention of pharmaceutical agents) supported through Merckâ&#x20AC;&#x2122;s speakerâ&#x20AC;&#x2122;s bureau, and owns stock in Labopharm (Canadian maker of trazadone).

Faculty Bios Dr. Culpepper is professor of family medicine and the founding chair of the Department of Family Medicine at Boston University School of Medicine. He is also chief of the Department of Family Medicine at Boston Medical Center. He received his medical degree from Baylor College of Medicine, Houston, Texas, and his MPH from Boston University. An active researcher, Dr. Culpepper has conducted federally-funded studies of depression and anxiety, otitis media, and school- and community-based interventions to improve pregnancy outcomes and to prevent teen pregnancies. Re-

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S A T U R D A Y

cently, he served as the principal investigator of an Agency for Healthcare Research and Quality (AHRQ)-funded developmental center for patient safety research devoted to the study of problems affecting low income and minority vulnerable populations in ambulatory care settings. In addition, he is a co-investigator of the Primary Care Anxiety Project, a study of the course of anxiety disorders in primary care settings. Dr. Culpepper served as President of the North American Primary Care Research Group (NAPCRG) and chair of the Research Committee of the Society of Teachers of Family Medicine (STFM). Dr. Culpepper chaired the primary care section of the 2011 annual meeting for the National Sleep Foundation. Jeffrey Luther, MD is Director of the Family Medicine Residency Program at Long Beach Memorial Medical Center and clinical professor in the Department of Family Medicine at the University of California, Irvine. He is a past president of the CAFP and also represents the Academy on the California Immunization Committee, an advisory body to the state Department of Public Health. Dr. Luther is currently involved in research concerning vaccine delivery and safety in conjunction with the American Academy of Pediatrics.

Support This session, in partnership with Asante Communications, is supported by an unrestricted educational grant from Cephalon.

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Schedule for Sunday, May 15, 2011_____________________________________

Page

9:00 -10:00 am

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Primary Prevention of Dementia: Evidence-Based Practical Recommendations

Christopher Flores, MD

10:00-11:00 am

Hepatitis B Update

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George Kent, MD

11:30-12:00 pm

The Many Faces of MRSA: Recognizing and Treating the New At-Risk Populations

Marshall Kubota, MD

12:30-1:45 pm

Lunch and Learn: Head Trauma: From Concussions to Traumatic Brain Injuries

Lee Ralph, MD; Lauren Simon, MD; and David Bazzo, MD

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Two Minutes, Two Slides, Two Questions

Davis Bazzo, MD and Company

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2:45-3:45 pm

HIT Meaningful Use 101: I Need to Register and Understand the Measures

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HIT Meaningful Use 201: Action Plan Elise Singer, MD

188

Michelle Quiogue, MD

1:45-2:30 pm

2:45-3:45 pm

S U N D A Y

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12:30-5:30 pm

SAMs Group #2: Health Behaviors

151

Pre-Registration Required

Elise Singer, MD

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Session #8: Sunday, May 15, 9:00-10:00 am Primary Prevention of Dementia:

Evidence-Based Practical Recommendations

Christopher Flores, MD Assistant Clinical Professor, Loma Linda University School of Medicine Assistant Clinical Professor, University of California, Davis School of Medicine Private practice, Rancho Mirage, CA

Activity Description Dr. Flores will engage the audience in a case-based interactive approach to understanding how to examine for dementia and cognitive impairment.

Learning Objectives

1. Define the link between cerebrovascular disease and cognitive impairment.

3. Identify dietary and nutritional patterns associated with healthy brain function and lower incidence of neurodegenerative disease and cognitive impairment.

2. Distinguish between neuropathologic findings and clinical correlates relating to dementia and normal brain aging.

4. Appreciate evidence supporting aerobic and resistance exercise as a factor in neurogenesis and modulation of neurodegenerative diseases. 5. Recognize the adverse effects of psychologic stress on memory and cognitive function and review validated stress-reduction techniques that patients can use to cope and deal with stress, including mindfulness-based meditation. 6. Critically appraise the role of various intellectual activities including proprietary computer-based games, life-long academic learning, and paper-based puzzles and brain games in maintaining.

Faculty Disclosure Dr. Flores declares that in the past 12 months neither he nor members of his immediate family have had financial relationships with the manufacturers of goods or services discussed in this activity.

Faculty Bio Christopher D. Flores, MD, completed his medical degree at the University of California, Irvine School of Medicine, while there he volunteered at the Orange County Community Clinic in Santa Ana. Dr. Flores completed a faculty residency program at University of California, San Francisco in the Department of Family and Community Medicine. There he developed a family practice curriculum in chronic non-malignant pain management. During his residency at Kaiser Permanente Los Angeles he initiated a resident-run high school clinic at Hollywood High School. Dr. Flores won â&#x20AC;&#x153;Teacher of the Yearâ&#x20AC;? in 2001 and 2004 at the San Joaquin General Hospital Family Practice Residency Program. Dr. Flores is currently assistant clinical professor at the Loma Linda University School of Medicine and assistant clinical professor at the University of California, Davis School of Medicine. 122

63rd CAFP Annual Scientific Assembly â&#x20AC;˘ San Francisco

Primary Prevention of Dementia – An Evidence Based Review Christopher V. Flores, MD Assistant Clinical Professor Loma Linda University

Faculty Disclaimer The CAFP Committee on Continuing Professional Development is responsible for management and resolution of conflict for any individual who may have influence on content, who have served as faculty, or who may produce CME/CPD content for the CAFP.

S U N D A Y

Christopher Flores, MD, discloses that he has no affiliation or financial interest in any organization.

Objectives 



Define link between cerebrovascular disease and cognitive impairment Identify diet and nutritional patterns associated with healthy brain function Appreciate evidence supporting benefits of exercise on brain health Appraise the role of cognitive training and stress reduction in maintaining cognition

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Case presentation 69 yo healthy female is in for annual physical. Her only active problems are:  Hypertension – 138/88 on lisinopril 10 mg daily  Osteopenia – on alendronate 70 mg weekly  Hypothyroid - levothyroxine 0.075 mg daily (TSH is 1.8)

Is my memory loss normal? She has noticed more difficulty:  Remembering names  Misplacing her keys  Forgetting why she went into a room  Her mother lived to early ‘90s and had “Alzheimer’s”

Normal exam 

   

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She does not have any serious memory loss impairing her function MMSE 30/30 Normal Clock Draw Test Normal animal naming test at one minute Normal neurologic exam including mental status, CN II-XII, Gross motor and sensory, DTR’s, Gait, and Balance

63rd CAFP Annual Scientific Assembly • San Francisco

Is she at risk for Alzheimers? 

 

She is reassured about your exam and the fact that everything appears normal “Is there any other test I can do?” “Is there anything else I can do to prevent dementia?”

What would you do? 1. MRI, PET, or other imaging 2. Recommend genetic testing 3. Referral to neurologist 4. Serum vitamin B12, Folate 5. Other/Do nothing more

S U N D A Y

Advice for her? 1. 2. 3. 4. 5.

Increase her lisinopril Take omega three supplement daily Increase physical exercise Specific cognitive training advice Stress management class or meditation

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Typical cognitive decline

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Dementia is a sloppy term   

Alzheimer’s ≠ Dementia MCI ≠ Dementia Dementia ≠ Dementia

S U N D A Y

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AD Pathology ≠ Dementia     

Atrophy on brain imaging (late sign) Beta-amyloid plaques (e.g. PET) Neurofibrillary tangles MRI Pathology and imaging evidence of AD does not correlate 100% with clinical dementia

What can we do to prevent dementia?  



Multiple risk factors are well-documented Many studies have identified lifestyle factors that are protective against dementia Ongoing current studies will help guide more precise interventions Patients are clamoring for this type of information

Business Case 



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$295 million spent on “brain boosting” products 2009 (35% growth from 2008) Top Interests and Concerns of AARP Members – #1: “Staying Sharp Mentally” Life Events Experienced by AARP Members Over Past Year – 9% – “Memory Loss”

63rd CAFP Annual Scientific Assembly • San Francisco

Epidemiology    

5.4 million Americans currently have AD By 2050, as many as 16 million 2/3 are women $183 billion – cost of providing care per year

Cognitive impairment with age 



There are normal cognitive changes associated with aging Loss of fluid intelligence and short term memory Loss of verbal language skills and word finding

S U N D A Y

Nutrition  

 



Mediterranean-type diet High in fresh fruits, vegetables, whole grains and legumes More fish, less red meat and milk MUFA – monounsaturated fatty acids (olive oil, nuts, avocados) Moderate alcohol (mainly red wine)

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Cardiovascular Risk Factors 



Vascular dementia often coexists with Alzheimer’s Disease – worsens cognitive deficit Reduced vascular disease → Reduced dementia Studies support this relationship

Nutrition – Omega Three 



Marine DHA and EPA dietary intake has been shown to confer protection from memory loss and cognitive impairment PUFA is important component of neuron cell membranes 60% less risk of Alzheimer’s in individuals who ate fish at least once per week

Nutrition – Vitamin Deficiencies 



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Vitamin B12 deficiency is known to cause neurologic, cognitive, and psychiatric symptoms Even low normal levels may contribute to memory loss and poor cognition Higher serum levels of vitamin B12 may confer protection against cognitive impairment

63rd CAFP Annual Scientific Assembly • San Francisco

Mediterranean Diet How much risk reduction? 1. 10% 2. 20% 3. 30% 4. 40% 5. 50%

Exercise – BDNF 



Brain Derived Neurotrophic Factor levels have been shown to increase in response to exercise in laboratory and animal models BDNF appears to benefit nerve cells

S U N D A Y

Exercise – Neurogenesis 



Multiple studies have shown the positive effect of physical exercise on cognition and hippocampus size Transgenic mouse studies have demonstrated exercise-induced neurogenesis in hippocampus

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Exercise – Studies Recent studies have demonstrated benefits to guide specific exercise prescriptions Exercise 3 or more times per week Walking is OK 2 miles per day average (roughly 30 minutes per day)



  

Exercise and hippocampus How much volume change after one year of walking 3 times per week? 1. 2% loss of volume 2. No change in volume 3. 2% increase in volume 4. 5% increase in volume

Body Mass Inflammation is linked to neurodegenerative changes in brain Central adipose deposition (“metabolic syndrome”) increases inflammation, hs CRP, etc. Lower body mass is linked to longevity and lower risk of memory loss



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Brain Fitness 



Cognitive Stimulation (CS) versus Cognitive Training (CT) CS = crosswords, sudoku, card games, jigsaw puzzles CT = rigorous and challenging activities that adapt to the skill level of individual

IMPACT Study How much improvement in memory? 1. 2 years 2. 5 years 3. 10 years 4. 15 years 5. 20 years

S U N D A Y

Social Isolation 



Multiple studies have demonstrated association between social isolation, loneliness, lack of friends and social support as risk factors for dementia Lonely people may be twice as likely to develop dementia

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Meditation 



Corticosteroids and cortisol negatively affect memory and cognition, and can be directly toxics to neurons (e.g. hippocampus) Mindfulness-Based Stress Reduction (MBSR), a clinically validated standardized curriculum has been shown to decrease stress and biomarkers like cortisol

Conclusions 

 

Clinical dementia is believed to be caused by multiple factors: neurodegenerative, vascular, inflammatory, and stress-related Aggressively Tx DM and CV risk factors Mediterranean diet, exercise, cognitive training, and stress reduction have the potential to attenuate this injury and delay or prevent onset of clinical dementia

Alzheimer’s Association “Trajectory” Initiative 



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An intervention breakthrough that delays onset of Alzheimer’s disease by 5 years would result in Reduction from 10% of seniors with Alzheimer’s disease to 7% in 2020 Reduction from 16% to 9% in 2050

63rd CAFP Annual Scientific Assembly • San Francisco

Thanks Questions?

S U N D A Y

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Primary Prevention of Dementia – Christopher V. Flores, MD References: 1. Ritchie K, Carnere I, et al. Designing Prevention Programmes to Reduce Incidence of Dementia: Propesctive cohort study of modifiable risk factors. BMJ 2010, 341:c3885 2. Kramer J, Jurick J, et al. Distinctive Neuropsychological Patterns in Fronto‐Temporal Dementia, Semantic Dementia, and Alzheimer’s Disease. Cognitive and Behavioral Neurology December 2003, 16(4);211‐218 3. Smith DL, Pozueta J, et al. Reversal of long‐term dendritic spine alterations in Alzheimer’s disease models. Proceedings of National Academy of Science 2009 September 29, 106(39):16877‐82 4. Shiroky JS, Schipper HM, et al. Can you have dementia with an MMSE score of 30? American Journal of Alzheimer’s Disease and Other Dementias. October/November 2007, 22(5): 406‐415 5. Schneider JA, Wilson RS, et al. Cerebral infarctions and the likelihood of dementia from Alzheimer’s disease pathology. Neurology 2004, 62:1148‐1155 6. Alzheimer’s Association, 2011 Alzheimer’s Disease Facts and Figures, Alzheimer’s and Dementia, Volume 7, Issue 2 – downloaded from http://www.alz.org/downloads/Facts_Figures_2011.pdf 7. Feart C, Samien C, et al. Adherence to a Mediterranean Diet, Cognitive Decline, and Risk of Dementia. JAMA 2009, 302(6): 638‐648. 8. Scarmeas N, Luchsinger J, et al. Physical Activity, Diet, and Risk of Alzheimer Disease. JAMA 2009, 302(6):627‐637 9. Erickson KI, Voss MW, et al. Exercise training increases size of hippocampus and improves memory. Proceedings of the National Academy of Sciences, February 2011, 108(7):3017‐3022 10. Smith GE, Housen P, et al. A cognitive training program based on principles of brain plasticity: The IMPACT study. Journal of the American Geriatrics Society April 2009. 57(4):594‐603 11. Geldmacher DS. Alzheimer disease prevention: Focus on cardiovascular risk, not amyloid? Cleveland Clinic Journal of Medicine 2010; 77(10):689‐704 12. Etgen T, Sander D, et al. Physical activity and incident cognitive impairment in elderly persons: the INVADE study. Arch Int Med 2010; 170:186‐193 13. NIH State‐of‐the‐Science Conference Statement: Preventing Alzheimer’s Disease and Cognitive Decline, Apr 2010 14. Bennett DA, Schneider JA, et al. Neuropathology of older persons without cognitive impairment from two community based studies. Neurology 2006:66:1837‐1844 15. Tyas SA; Snowdon DA, et al. Healthy Aging in the Nun Study: Definition and Neuropathologic Correlates. Age and Ageing 2007: 36;650‐655 16. Erikson KI, Raji CA, et al. Physical activity predicts gray matter volume in late adulthood: The Cardiovascular Health Study. Neurology 2010; 75:1415 17. Zedan S, Johnson S, et al. Mindfulness Meditation Improves Cognition: Evidence of Brief Mental Training. Consciousness and Cognition 2010: 19(2):597‐605 18. Xiong GL; Doaraiswamy PM. Does meditation enhance cognition and brain plasticity? Annals NY Acad Sci 2009. 1172:63‐69

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Session #9: Sunday, May 15, 10:00-11:00 am Understanding Hepatitis B

George P. Kent, MD Adjunct Clinical Professor Stanford University Division of Community and Family Medicine Associate Director O’Connor-San Jose Family Medicine Residency Program

Activity Description Dr. Kent will use a case-based approach to discuss with the audience best practices in identifying and screening patients, understanding the natural history of the disease, and determining how to evaluate and treat Hepatitis B.

Learning Objectives

1. Identify and screen patients at risk for Hepatitis B.

3. Perform laboratory evaluation to identify patients with Hepatitis B.

2. Discuss the natural history of Hepatitis B infection.

4. Discuss recommended protocols to monitor chronic infection and disease progression. 5. List treatment options.

6. Counsel patients and their families.

7. Collaborate appropriately with subspecialists.

Faculty Disclosure Dr. Kent declares that in the past 12 months neither he nor members of his immediate family have had financial relationships with the manufacturers of goods or services discussed in this activity.

Faculty Bio George Kent, MD, earned his medical degree at Case Western Reserve University School of Medicine and completed a preventive medicine residency at the Centers for Disease Control. He also completed a residency at University of California San Francisco Community Hospital of Sonoma County. Because of his fluency in Spanish, Dr. Kent’s career he has volunteered for international projects to provide medical care or to train health professionals in rural Mexico and Central America, consulted with the Republic of Panama on STDs and HIV prevention, and co-translated a health care manual for rural care workers. Locally, Dr. Kent has conducted grand rounds on a breadth of primary care topics such as immunization, antibiotic resistance, women and AIDS, hypertension, hepatitis, tuberculosis and immigrant care. Dr. Kent has authored papers on STDs, public health and the water supply, hurricane and emergency room visits, and acupuncture-associated Hepatitis B. In addition to his academic position in Family and Community Medicine at Stanford, Dr. Kent serves as medical director of the O’Connor-San Jose Family Health Center.

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S U N D A Y

Understanding Hepatitis B

CAFP Scientific Assembly May 2011 George Kent, MD

Faculty Disclosure The CAFP Committee on Continuing Professional Development is responsible for management and resolution of conflict for any individual who may have influence on content, who have served as faculty, or who may produce CME/CPD content for the CAFP.

George Kent, MD, discloses that he has no affiliation or financial interest in any organization.

Educational Objectives  Identify and screen patients at risk for

Hepatitis B  Discuss the natural history of Hepatitis B

infection  Perform laboratory evaluations to identify

patients with Hepatitis B

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63rd CAFP Annual Scientific Assembly • San Francisco

Educational Objectives 

Discuss recommended protocols to monitor chronic infection and disease progression



List treatment options



Counsel patients and their families



Collaborate appropriately with subspecialists

A 49-year-old woman presents for her first visit, requesting a physical examination. She was born in Viet Nam and tells you that her older brother was just diagnosed with liver cancer.

S U N D A Y

She wants to know if she is at risk. She was told that she was exposed to hepatitis B but has not had any lab work for more than 10 years.

How comfortable are you with screening and advising patients with hepatitis B? On a scale of 1-8, with 8 being most comfortable: 1: 3: 6: 8:

I’m CLUELESS. I’m going to refer her immediately as soon as she’s out the door I’ll muddle through today with a hepatitis panel and some reassuring words, but I’ll refer her to a specialist for the workup I know how to get started. I know what initial lab work to order and can give her some general advice before referring No problem. Just another patient with hepatitis B

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 Approximately 1.2 million chronic HBV carriers in the US, an

estimated 11,000 to 17,000 hospitalizations/year, and 4,000 to 5,500 deaths/year.1  15-40% of Hepatitis B chronic carriers will develop complications during their lifetime.2  In California, HBV-related hospitalizations for liver disease, liver cancer, and liver transplants cost $316 million in 2007.3  Approximately 1 in 10 Asian-Pacific Islanders in California has chronic HBV.4 1. Lavanchy D. Hepatitis B virus epidemiology, disease burden, treatment, and current and emerging prevention and control measures. J Viral Hepat 2004;11(2):97-107. 2. Bosch FX, Ribes J, Cleries R, Diaz M. Epidemiology of hepatocellular carcinoma. Clin Liver Dis 2005;9(2):191-211 3. California Department of Public Health IB, 2007. 4. Lin SY et al. Hepatology. Oct 2007;46(4):1034-1040.

Geographic Distribution of Chronic Hepatitis B Infection

HBsAg Prevalence 8% - High 2-7% - Intermediate <2% - Low

Hepatitis B: Clinical features • Incubation period: • Clinical illness (jaundice): • Acute case-fatality rate: • Chronic infection: • Premature mortality from chronic liver disease:

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Average 60-90 days Range 45-180 days <5 yrs: <10% >5 yrs: 30%-50% 0.5%-1% <5 yrs: 30%-90% >5 yrs: 2%-10% 15%-25%

63rd CAFP Annual Scientific Assembly • San Francisco

Clinical course of hepatitis B by age at initial infection

100 80

80 60

Chronic Infection

40 20

20 0

Symptomatic Infection 1-6 months

Birth

7-12 months

1-4 years

Age at Infection

Surface antigen

Envelope antigen

Symptomatic Infection (%)

Chronic Infection (%)

100

0 Older Children and Adults

Core antigen

S U N D A Y

Hepatitis B Virus Structure Diagram courtesy of Swiss Institute of Bioinformatics

Acute HBV Infection With Recovery Typical Serologic Course Symptoms anti-HBe

HBeAg HBV DNA

Titer

anti-HBs

IgM anti-HBc

HBsAg

0 Source: CDC

Total anti-HBc

100

Weeks of Exposure

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Progression to Chronic HBV Infection Typical Serologic Course (simplified) HBV DNA

HBeAg

anti-HBe HBsAg Total anti-HBc

Titer

IgM anti-HBc

12 16 20 24 28 32 36

 HBsAg: virus is present; infection

has not cleared

 Chronic carrier: +HBsAg for more

than 6 months

Years

Weeks of Exposure

Source: CDC

 HBeAg: hepatitis B envelope

antigen; active viral replication; at risk for progressive liver disease. May be absent with mutant virus (HBV DNA is still positive)

 anti-HBe: antibody to HBeAg;

 anti-HBs: patient is immune if

reduced viral replication

antibody is present

 HBV DNA: (quantitative) measures

 anti-HBcIgM: indicates recent

infection; usually disappears within 6 months of infection

 anti-HBc: total antibody to hepatitis

degree of viremia

 HBV Genotype: (A-H) Useful if

interferon considered

B core antigen; indicates previous infection

Stages of Chronic Hepatitis B

HBeAg-negative chronic hepatitis

Precore/ Core promoter mutation

142

10-30%

Negative HBeAg HBV DNA  Abnormal ALT

Immune tolerance

age 30-40

Positive HBeAg HBV DNA  Normal ALT Progression to cirrhosis

Inactive carrier

(0.5%/yr clear HBsAg)

Negative HBeAg HBV DNA Low Normal ALT

HBeAg-positive chronic hepatitis Positive HBeAg HBV DNA  Abnormal ALT 20%

Perinatal transmission

8-12%/yr

HBeAg seroconversion or reactivation

63rd CAFP Annual Scientific Assembly • San Francisco

 REVEAL: Long-term follow-up of untreated HBsAg positive individuals in Taiwan

Patients (%)

Cumulative Incidence of HCC at Year 13 Follow-up[1] (N = 3653)

Cumulative Incidence of Cirrhosis at Year 13 Follow-up[2] (N = 3582) 36.2

23.5

12.2

10 0

1.3

1.4

3.6

< 300

300999

10009999

10,00099,999

14.9

≥100,000

4.5

5.9

< 300

3009999

9.8

10,00099,999

100,000- ≥1 million 999,999

Baseline HBV DNA (copies/mL) 1. Chen CJ, et al. JAMA. 2006;295:65-73. 2. Iloeje UH, et al. Gastroenterology. 2006;130:678-686.

Chronic Hepatitis B: Key Points  Perinatally-acquired HBV poses a lifelong risk of

hepatocellular carcinoma (HCC) and cirrhosis  Anticipate development of hepatitis by age 40  Many are candidates for therapy—refer as

S U N D A Y

needed

 “Inactive carriers” may not remain inactive; they

could reactivate, increasing risk for complications  For patients with HBV infection, ALT > 20 in women, ALT > 30 in men is ABNORMAL

 Patients originating from endemic areas  Those with risk factors for HBV infection:  MSM  Multiple sexual partners  IVDU  Inmates of correctional facilities  Elevated LFT’s  Close contacts of Hepatitis B chronic carriers  Screening test:  HBsAg and anti-HBs  Alternatively, anti-HBc (total), then obtain HBsAg and anti-

HBs if positive

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 Physical exam

 Signs of decompensated cirrhosis:

 Ascites, encephalopathy, variceal bleed

 Compensated cirrhosis

 May be asymptomati

 Decreased platelets, elevated AP, bilirubin  Biopsy-proven   Lab data: CBC, chemistry, LFT’s, INR, HBeAg, anti-HBe, HBV

DNA, Hepatitis A and C serology (immunize against HAV if susceptible), HIV, Alpha-Fetoprotein  Liver ultrasound

 Every 6 months  ALT, Alpha-fetoprotein

(sensitivity only 60% at > 20 ng/ml)

 At least every year  Liver ultrasound (sensitivity 65-80%, specificity 90%)  Less sensitive in obese patients; consider MRI with contrast

or triphasic CT scan to confirm

 Screen more frequently (every 6 months) in carriers with

cirrhosis, family history of HCC

 If ALT becomes abnormal in an inactive carrier:  Evaluate for reactivation of hepatitis B  HBV DNA, HBeAg, Liver U/S, consider biopsy

Prevention of Hepatitis B  Immunize close contacts of carriers  Universal immunization of infants at birth  Prenatal hepatitis screening

 Immediate HBV vaccine and HBIG

after birth for infants of HBsAg+ mothers  Post-exposure prophylaxis  Immediate HBV vaccine and HBIG

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63rd CAFP Annual Scientific Assembly • San Francisco

Counseling HBsAg+ patients to prevent transmission of hepatitis B  Immunize sexual contacts

 Use barrier protection if partner not

immune

 Not share toothbrushes or razors  Cover open cuts

 Clean blood spills with detergent or

bleach

 Do not donate blood or organs

Children and adults who are HBsAg+:

 Can participate in all activities including contact sports

 Should not be excluded from daycare or school participation  Can share food, utensils, or kiss others

Treatment of Chronic Hepatitis B The question is not WHOM to treat, but rather WHEN to treat!

S U N D A Y

Deciding When to Treat 2 elements:  Liver inflammation: ALT, biopsy results  Viral load: HBeAg+: >20,000; HBeAg-: >2000 Factors promoting disease progression Host Factors

Virus Factors

Environmental

Age > 40*

High levels of HBV-DNA*

Alcohol use*

Male*

Genotype (C > B)*

Aflatoxin*

Family History of HCC*

HBV variant

Obesity?

Immune status

Yim JY, Lok AS. Hepatology 2006;43:S173-181

Coinfection HCV/ HIV * supported by strong evidence

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Recommendations for first-line therapy PREFERRED

ALTERNATIVE

NOT PREFERRED

Tenofovir

Adefovir

Lamivudine

Entecavir

Telbivudine

Peg-IFN 2-α

Keeffe et al. Clin Gastroenterol Hepatol 2008;6:1315-1341. Lok AS, McMahon BJ. Hepatology 2009;50:661-662.

Tenofovir*, Entecavir*, Adefovir, Lamivudine, Telbivudine  Advantages:  Easy to take  Few side effects  Minimal monitoring  Can be given to patients

with decompensated cirrhosis

 Disadvantages:  Resistant strains can

develop with monotherapy

 If HIV+, cannot use

monotherapy

 Will likely need prolonged

therapy (not a cure)

(*=preferred)

HBeAg (+) Chronic hepatitis B Results after 1 year of therapy (separate studies)

EASL Clinical Practice Guidelines. J Hepatology 2009;50:227-242

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63rd CAFP Annual Scientific Assembly • San Francisco

HBeAg (–) chronic hepatitis B Results after 1 year of therapy (separate studies)

EASL Clinical Practice Guidelines. J Hepatology 2009;50:227-242

 Advantages:

 No evidence of viral resistance  Limited duration of therapy  HBeAg +: 4-8 months

 HBeAg -: 12-24 months

 3-year follow-up of HBeAg+ responders:

81% remained HBeAg-; 30% also lost HBsAg1

S U N D A Y

 Genotype A and B strains respond best

 Best candidate: younger, HBeAg+, elevated ALT  Disadvantages:

 Multiple injections

 Frequent side effects, some potentially serious 1. Buster EH, et al. Gastroenterology 2008;135:459-467.

HBV is always hiding somewhere…. Even if + anti-HBs, HBV DNA is hiding in the nucleus!

Virus could re-emerge if immunosuppressed!

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HBV and immunosuppression 

Immunosuppression allows viral replication

 Anti-TNF therapy, chemotherapy, corticosteroids 

2008 CDC recommendation:

 “Screen all persons needing immunosuppressive

therapy including chemotherapy, and immunosuppression for GI and rheumatologic disorders.”

CDC. MMWR 2008;57(RR-8):9-10.

Recommendations for screening prior to immunosuppressive therapy  HBsAg, anti-HBc (total)

 If positive for either, measure HBV DNA

 IF HBV DNA is detectable:

 Start antiviral therapy before initiating immunosuppressive

therapy

 HBsAg-, HBV DNA-, but positive anti-HBc: indicates prior

infection  These patients are not completely “immune”  HBV could reactivate if immunosuppressed  Monitor HBV DNA during treatment CDC. MMWR 2008;57(RR-8):9-10. CDC. MMWR 2008;57(RR-8):9-10. Lok AS, McMahon BJ. Hepatology 2009;50:661-662.

People with hepatitis B Need lifelong monitoring  HBV is an oncogenic virus  Even “immune” patients have a risk of developing HCC,

especially if they were infected at birth

 Patients with HBV infection at

any stage need lifelong monitoring!  Primary care physician, collaborating with gastroenterologist

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63rd CAFP Annual Scientific Assembly • San Francisco

References  Lok A, McMahon B. AASLD Practice Guideline Update:

Chronic Hepatitis B: Update 2009. Hepatology Sep 2009.

 Mc Mahon, B. The Natural History of Hepatitis B.

Hepatology May 2009; S45-55.

 Keeffe EB, et al. A Treatment Algorithm for the Management

of Chronic Hepatitis B Virus Infection in the United States: 2008 Update. Clinical Gastroenterology and Hepatology 2008;6:1315–1341.

A 49 year-old woman presents for her first visit, requesting a physical examination. She was born in Viet Nam and tells you that her older brother was just diagnosed with liver cancer.

S U N D A Y

She wants to know if she is at risk. She was told that she was exposed to hepatitis B but has not had any lab work for over 10 years.

How comfortable are you with screening and advising patients with hepatitis B? On a scale of 1-8, with 8 being most comfortable: 1: 3: 6: 8:

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Thank you!

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63rd CAFP Annual Scientific Assembly â&#x20AC;˘ San Francisco

Session #10: Sunday, May 15, 11:30 am-12:30 pm The Many Faces of MRSA: Recognizing and Treating the New At-Risk Populations

Marshall Kubota, MD Professor of Family Medicine University of California San Francisco Medical Director, North Coast Area AIDS Education and Training Center

Activity Description Dr. Kubota will present an in-depth session to investigate the evidence basis for prevention, identification, diagnoses and differential treatment options for patients with MRSA.

Learning Objectives

1. Facilitate accurate diagnosis of MRSA in patients with suppurative skin infections.

2. Implement the latest recommendations for treatment of methicillin-resistant Staphylococcus aureus skin and soft tissue infections.

3. Identify patients who can be managed with non-pharmacologic versus pharmacologic treatment in the community versus patients who may require surgical consultation and/or hospitalization for severe or complicated infections.

S U N D A Y

Faculty Disclosure Dr. Marshall Kubota declares that during the past 12 months he has consulted and/or received honoraria from Boehringer Ingelheim, ViiV and Gilead Sciences.

Faculty Bio Marshall Kubota, MD, completed his medical degree at Saint Louis University School of Medicine and did his residency at Sutter Medical Center of Santa Rosa. Dr. Kubota is currently medical director of both the North Coast Area AIDS Education and Training Center and Public Health Clinical Services for Sonoma Department of Health Services. He is also the founder of the Sonoma County Center for HIV Prevention and Care.

Support This activity is supported by an unrestricted educational grant from Pfizer.

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The Many Faces of MRSA: Recognizing and Treating the New At‐Risk Populations May 15, 2011 CAFP’s 63rd Annual Scientific Assembly

California Academy of Family Physicians

2011

Today’s Faculty Marshall Kubota, MD Clinical Professor Department of Family and Community Medicine University of California, San Francisco

2011 | California Academy of Family Physicians

Faculty Declarations 



Dr. Marshall declares that during the past 12 months he has consulted and/or received honoraria from Boehringer Ingelheim, ViiV and Gilead Sciences. 2011 | California Academy of Family Physicians

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Industry Support 



2011 | California Academy of Family Physicians

Learning Objectives After this presentation you should be able to: 



Facilitate accurate diagnosis of MRSA in patients with suppurative skin infections Implement the latest recommendations for treatment of methicillin‐resistant Staphylococcus aureus skin and soft tissue infections. Identify patients who can be managed with nonpharmacologic vs pharmacologic treatment in the community vs patients who may require surgical consultation and/or hospitalization for severe or complicated infections

S U N D A Y

2011 | California Academy of Family Physicians

Have you treated a case of MRSA? 1. 2. 3.

Yes No Not in clinical medicine

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Staphylococcus aureus 

Staphylococcus aureus is a leading cause of human bacterial infections worldwide.1 



severity of these infections varies widely—from minor skin infections to fatal necrotizing fasciitis and pneumonia.

Traditionally, Methicillin‐Resistant Staphylococcus aureus (MRSA) infections were confined to the healthcare environment. Over the past decade, however, the prevalence of community‐associated MRSA (CA‐MRSA) has increased exponentially. 

In many parts of North America, MRSA is now the most common identifiable cause of soft‐tissue infection among persons from the community without healthcare contactworldwide.2

1Diekema DJ, Pfaller

MA, Schmitz FJ, et al. Survey of infections due to Staphylococcus species, 1997–1999. Clin Infect Dis 2001; 32 (suppl 2): S114–32. 2Daum RS.: Clinical practice. Skin and soft‐tissue infections caused by methicillin‐resistant Staphylococcus aureus. N. Engl. J. Med. 357(4), 380–390 (2007).

Methicillin‐Resistant Staphylococcus aureus (MRSA) 



Many community‐associated MRSA (CA‐MRSA) infections arise in otherwise healthy individuals who do not have such risk factors. CA‐MRSA strains appear to be more virulent and transmissible than are traditional hospital‐associated MRSA strains. The lines between hospital and community are blurring with regard to MRSA. CA‐MRSA has caused hospital outbreaks and HCA‐MRSA has moved into the community.

http://www.med.unc.edu/intselect/files/CA‐MRSA%20Lancet%20Review%202010.pdf

Community‐Associated MRSA (CA‐MRSA) 



A new strain of MRSA presenting from the community in persons without traditional risk factors for MRSA Differing from HCA‐MRSA in terms of     



Epidemiology Antibiotic sensitivity patterns Virulence Presentation Treatment

Thought to have evolved separately in the community based on genetic differences1

1Said‐Salim B, Mathema B, Kreiswirth BN. Community‐Acquired Methicillin‐Resistant Staphylococcus aureus: An Emerging Pathogen. Infection Control and Hospital Epidemiology 2003;24:451‐455.

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CA‐MRSA 



Most common pathogen among patients with skin and soft tissue infections (SSTIs) seeking treatment More than 90% of CA‐MRSA are skin infections (abscesses or cellulitis with purulent drainage) However, some unusual, particularly virulent infections ‐ including necrotizing pneumonia, necrotizing fasciitis, and sepsis ‐ are also seen. 2011 | California Academy of Family Physicians

CA‐MRSA 

Risk Groups:            

Jail or incarceration Exposure to recent antibiotics Daycare exposure Military personnel Native Americans African Americans Close contact sports (wrestling/football) HIV infections Low socioeconomic backgrounds Children Young adults Ethnic backgrounds



    

Factors conducive to spread of the bacteria include: Close skin to skin contact Cuts or abrasions Shared contaminated items or surfaces Poor hygiene Crowded living conditions

S U N D A Y

Diagnosis

2011 | California Academy of Family Physicians

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Possible Presentations         

Impetigo Cellulitus without abscess Furuncles – hair follicle infection Carbuncles – local, deep skin infection Staphylococcal food poisoning Abscesses Folliculitis Infected lacerations Other

Symptoms – Local 

Localized symptoms may include:  Drainage of pus or other fluids from the site  Fever  Skin abscess  Surrounding cellulitis

Symptoms – Systemic 

Systemic symptoms of a more serious staph infection may include:         

Chest pain Chills Fatigue Fever General malaise Headache Muscle aches Rash Shortness of breath

2011 | California Academy of Family Physicians

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Rapid Diagnostic Testing 



Routine bacterial cultures and susceptibility testing may take 48 to 72 hours for detection of the pathogen. Rapid diagnosis of MRSA infections is becoming increasingly important to ensure positive outcomes in therapeutic management. 2011 | California Academy of Family Physicians

Sampling of CLIA‐waived tests  Cepheid’s Xpert MRSA Test (GeneXpert system)  BD GeneOhm  Remel Spectra MRSA

S U N D A Y

 Oxoid PBP2' (MRSA) Latex Agglutination Test Kit  Tem‐PCR  Prove‐itTM

Spread of MRSA/Prevention

2011 | California Academy of Family Physicians

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The Spread of MRSA 



MRSA has emerged as one of the predominant pathogens in healthcare‐associated infections Treatment options for MRSA are limited and less effective than options available for susceptible S. aureus infections and result in higher morbidity and mortality High prevalence influences unfavorable antibiotic prescribing, which contributes to further spread of resistance prevalent MRSA more vancomycin use more vancomycin resistance (VRE and VRSA) more linezolid/daptomycin use more resistance 2011 | California Academy of Family Physicians

The Spread of MRSA 

Colonization: the state of a microorganism living in or on a body without causing disease 



25%‐ 30% of the general population are nasal carriers

Carriage of MRSA is much less common, but increasing; one study showed an increase in children in Nashville, Tennessee, from 0.8% in 2001 to 9% in 2005.1 Sources other than the nose are also important (throat, axilla, groin, and perirectal area).

1Klevens RM, Morrison MA, Nadle J, et al; Active Bacterial Core surveillance (ABCs) MRSA Investigators. Invasive

MRSA infections in the United States. JAMA. 2007;298:1763‐1771.

The Spread of MRSA 



158

Autoinfection or self infection: infection caused by direct contact with own skin lesions or pus or colonized skin  Account for 1/3 of all cases Fomites  Stethoscopes and neckties Most common source of spread:  Direct contact with persons with a draining lesions or pus Most common instrument for spread:  HANDS!

63rd CAFP Annual Scientific Assembly • San Francisco

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The Spread of MRSA 



A draining wound should be kept dry and covered. Appropriate wound care (clean, dry bandages) Alcohol‐based hand rubs (hand sanitizers) Antibacterial soaps



S aureus can contaminate almost anything –    



Clothing Bedding, Towels Razors Clean countertops, toilet seats, door knobs, bath tubs Equipment, towels, benches (athletes) Dry clothes in high heat

2011 | California Academy of Family Physicians

Settings for MRSA: Five Cs 

The US Centers for Disease Control and Prevention (CDC) emphasize 5 “C” factors: Crowding; Contact (skin‐skin);  Compromised skin integrity;  Contaminated items/surfaces; and  Cleanliness.  



S U N D A Y

Locations where the 5 Cs are common include schools, dormitories, military barracks, households, correctional facilities, and daycare centers. 2011 | California Academy of Family Physicians

Prevention Strategies    

Assessing hand hygiene practices Implementing contact precautions Recognizing previously colonized patients Rapidly reporting MRSA lab results

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Treatment

2011 | California Academy of Family Physicians

John – 29 y.o. man   

Presents with a painful lesion on the thigh Began 4 days ago There is a central hot red center Weeping serous fluid Surrounded by a ring of erythema  Tense swelling  Vitals: T 99.2F, BP 132/82, P 79  The remainder of the exam is unremarkable  

2011 | California Academy of Family Physicians

How would you treat John? 1. 2. 3.

Antibiotics and culture only Incision and drainage and culture only Incision and drainage plus treat orally for MSSA and culture Incision and drainage and treat orally for MRSA and culture Incision and drainage and treat intravenously for MRSA and culture

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MSSA v MRSA Treatment Guidelines 

In the case of methicillin‐susceptible Staphylococcus aureus (MSSA), the CDC (2006) suggests that a beta‐ lactam agent (anti‐staphylococcal penicillin or cephalosporin) is still a reasonable option for first‐ line therapy in the patient with mild to moderate illness and no significant co‐morbidities if the local prevalence of methicillin‐resistance among community S. aureus isolates is low.

2011 | California Academy of Family Physicians

Infectious Diseases Society of America (IDSA) Guidelines  



Released in January, 2011 Constitutes the first guidelines of the IDSA on the treatment of MRSA infections. The primary objective of the guidelines is to provide recommendations on the management of some of the most common clinical syndromes encountered by adult and pediatric clinicians who care for patients with MRSA infections. www.idsociety.org

S U N D A Y

Liu C et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin‐resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011 Feb 1; 52:285.

IDSA recommendations 



For simple MRSA skin abscesses, incision and drainage alone is probably adequate. Outpatients with purulent cellulitis should receive empirical therapy for community‐associated MRSA pending culture results; those with nonpurulent cellulitis should receive empirical therapy for β‐hemolytic streptococci. If, despite optimized wound care and hygiene, a patient develops multiple recurrent skin or soft‐tissue infections, or transmission is ongoing among household members or other close contacts, decolonization strategies may be considered. For patients with osteomyelitis, device‐related osteoarticular infections, or prosthetic valve endocarditis, rifampin can be used in conjunction with other antibiotics. 2011 | California Academy of Family Physicians

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Simple Incision and Drainage … A stick to your guns choice 



   

The choice of treatment is based on the history, coexisting conditions and physical findings The primary treatment of an uncomplicated CA‐MRSA abscess is incision and drainage May be curative and require no antibiotics Explore the wound with a probe to break up any loculations May need packing and replacement Not recommended for infections    

Face Hands Tissue planes Toes in circulation compromised or immunocompromised patients 2011 | California Academy of Family Physicians

Antimicrobial Therapy 



The CDC suggests that empiric antimicrobial therapy may be administered in addition to incision and drainage for some patients with purulent skin lesions. Deleo and colleagues1 suggest antibiotics if 1 or more of the following are present      

Extensive disease Signs of systemic illness Comorbidities or immunosuppression Age extremes Abscess in a location that is hard to drain Failure to respond to drainage

1Deleo F, Otto M, Kreiswirth

B, Chambers HF. Community‐associated methicillin‐resistant Staphylococcus aureus. Lancet. 2010;375:1557‐1568.

Antimicrobial Therapy 



If antibiotic treatment is clinically indicated, it should be guided by the susceptibility profile of the organism. CA‐MRSA strains are broadly resistant to almost all β‐lactam antibiotics Treatment options for minor, community‐acquired MRSA infections   



TMP/SMX – (not FDA indicated for Staph infections) Clindamycin Tetracycline derivatives – minocycline or doxycycline

Pediatric considerations …

2011 | California Academy of Family Physicians

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Antimicrobial Therapy 

If you choose to treat with antibiotics, can you afford to treat for MSSA for 48 hours awaiting routine culture and sensitivity 



    

If rapid sensitivity testing is not available

YES

Small (< 2 cm) drained abscesses or small areas of cellulitis Impetigo (can be treated with mupirocin) Isolated, non‐fluctuant lymph nodes Good follow‐up can be ensured

If YES, 

An oral anti‐staphylococcal beta‐lactam   



Cephalexin Cefadroxil Dicloxacillin

TMP‐SMX

2011 | California Academy of Family Physicians

For “sicker” Patients: Presumptive MRSA treatment Lesions on the face (non‐impetigenous) Febrile or ill‐appearing patients Lesions deeper than the skin Lesions on the hands or feet (except paronychia), genitalia Rapidly progressing infections Follow‐up questionable (weekends, holidays) 

  

 

S U N D A Y

Oral Treatment Oral clindamycin TMP/SMX (not FDA approved) Tetracycline derivative (doxycycline or minocycline) – will require a beta lactam to cover streptococci Linezolid

IV antibiotic 2011 | California Academy of Family Physicians

Hospitalization 

Complicated SSTI (cSSTI) Deeper infections, major abscesses, surgical or traumatic infections, cellulitis, infected ulcers and burns)  Debridement 



Antibiotics IV vancomycin (TDM guided) Linezolid  Daptomycin  Telavancin  Clindamycin (high dose)  

2011 | California Academy of Family Physicians

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Specific Concerns    



Endocarditis, prosthetic valve Pneumonia, empyema Meningitis, brain abscess Osteomyelitis, septic arthritis, prostheses and devices Neonatal, pediatric

2011 | California Academy of Family Physicians

New Drugs for MRSA     

Linezolid* Daptomycin* Telavancin (adults)* Ceftaroline injections Tigecyclin (adults)

*IDSA guideline recommended

2011 | California Academy of Family Physicians

35 y.o. man with multiple lesions     

164

Multiple lesions of various ages Some painful others not Some with purulent discharge Afebrile Similar episode of MRSA four months previously

63rd CAFP Annual Scientific Assembly • San Francisco

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How would you treat this patient? 1. 2. 3. 4.

Trial of MSSA antibiotics and culture Treat without culture I & D of lesions only and culture I & D of lesions and treatment for MRSA and culture I & D of lesions, treat for MRSA and consider decolonization 2 and 5 2011 | California Academy of Family Physicians

Decolonization for Recurrent Infections* 



 



*Experts define recurrent disease as 2 or more discrete SSTI episodes at different sites over a 6‐ month period. Question Patient (willing or unwilling participant); in high risk situation (dorms, sports team, crowded environment) 2‐4 recurrent infections Possible antibiotic usage (active infection only) Practice good hygiene!

S U N D A Y

Decolonization for Recurrent Infections 

Nasal Decolonization 



Mupirocin (twice daily, 5‐10 days)

Oral antibiotics are not routinely recommended for decolonization efforts Body Decolonization  

Chlorhexidine Bleach baths (children), 1 tsp. per gallon of water, 15 min twice weekly for ~3 months*

*Liu C et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin‐resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011 Feb 1; 52:285.

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Decolonization for Recurrent Infections 

 

Decolonize other people in the household? Pets? Personal Hygiene! Contacts should be evaluated for evidence of S. aureus infection: Symptomatic contacts should be evaluated and treated; nasal and topical body decolonization strategies may be considered following treatment of active infection.  Nasal and topical body decolonization of asymptomatic household contacts may be considered. 

Liu C et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin‐ resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011 Feb 1; 52:285.

After a MRSA patient visit   

Clean hands before and after all patient contacts. Glove when managing wounds, carefully dispose of dressings Clean contaminated surfaces with commercial disinfectant or a 1:100 solution of diluted bleach (15 ml bleach : one qt of water). 

 



exam table, switches, doorknobs

Launder potential contaminated linens in hot water (>160° F). Flag patient records, adding to the problem list to ensure contact precautions when patients previously treated for MRSA infections return. Provide education and training on risks and prevention of MRSA transmission during orientation and periodic educational updates for healthcare personnel. 2011 | California Academy of Family Physicians

Antimicrobial Stewardship 

Antimicrobial resistance is a major and growing issue in infection control, and antimicrobial stewardship programs are necessary in order to slow this process and maintain the utility of antibiotics for as long as possible.  Avoid inappropriate or excessive antibiotic prophylaxis and therapy.  Ensure correct dosage and duration of antibiotic therapy.  Restrict the use of vancomycin (if possible and appropriate for care of the individual patient being treated) to decrease the selective pressure favoring vancomycin resistance.  To prevent the establishment of VRE intestinal colonization, decrease the use of agents with little or no activity against enterococci, such as third‐generation and fourth‐generation cephalosporins, in patients not known to be VRE colonized (if possible and appropriate for care of the individual patient being treated). 2011 | California Academy of Family Physicians

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Antimicrobial Stewardship 



To prevent persistent high‐density VRE colonization, decrease the use of anti‐anaerobic agents in patients with known VRE intestinal colonization (if possible and appropriate for care of the individual patient being treated). To help prevent persistent carriage of MRSA, avoid unnecessary antibiotic use. Avoid therapy for decolonization except when suppression or eradication of colonization is being attempted using an evidence‐ based approach for infection prevention.

2011 | California Academy of Family Physicians

Take Home Points 1. 2. 3. 4. 5. 6.

Suspect MRSA for skin abscesses and other purulent infections Simple I & D for simple abscesses Culture and treat or change based upon the results Antibiotics for more than simple abscesses or for at risk individuals Hospitalization if needed In‐practice hygiene

S U N D A Y

2011 | California Academy of Family Physicians

WASH YOUR HANDS! 



Don’t infect or colonize yourself Don’t spread MRSA to other patients Don’t bring it home

2011 | California Academy of Family Physicians

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Thank You Questions?

2011 | California Academy of Family Physicians

Resources 

Infectious Diseases Society of America (IDSA)  



Released guidelines in January, 2011 Constitutes the first guidelines of the IDSA on the treatment of MRSA infections.

www.idsociety.org

2011 | California Academy of Family Physicians

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Session #11: Sunday, May 15, 12:30-1:45 pm Head Trauma: From Concussions to Traumatic Brain Injuries Lee Ralph, MD Associate Clinical Professor, Family Medicine University of California, San Diego Private practice, San Diego Sports Medicine and Family Health Center San Diego, CA Lauren Simon, MD Associate Professor, Family Medicine Assistant Program Director, Primary Care Sports Medicine Loma Linda University School of Medicine Riverside, CA David Bazzo, MD Clinical Professor of Family Medicine University of California, San Diego PACE/C-CHIP/QICM Office San Diego, CA

S U N D A Y

Activity Description

CAFP is in the development stage of a statewide (and potentially national) initiative to address the issues of head trauma, concussion, traumatic brain injuries and the family physicians’ role in the prevention, diagnosis, care and communications required to stem the rise of these conditions. Our three faculty members will discuss the clinical issues, and highlight practice resources for your practice.

Learning Objectives

1. Complete a self-assessment on baseline questions re: consensus guidelines, CIF guidelines, prevalence in their practices, referral patterns, need for additional assistance in managing head injured patients, use of head injury patient instruction sheets.

2. Discuss mechanisms of injury, why important, relevance to their practices, previous guidelines (Cantu, AAN, etc..) military research on MTBI, NFL Registry, CIF issues, review of International Consensus statement for Concussion in Sports-Zurich(focus on this!).

3. Engage in an appropriate neuro exam, SCAT-2 test, including imaging rules for CT vs. MRI, SPEC, functional MRI, MEG, and complete a brief review of types of bleeds(subdural, epidural, intracerebral, subarachnoid).

4. Assess cultural differences in treatment/management of head injuries in practice.

5. In small groups, talk about “a bruised brain is a big deal,” “play it safer,” document properly, physical and mental rest, dispel the myth of “playing hurt,” “don’t have all the answers.”

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Faculty Disclosures Drs. Ralph, Simon and Bazzo declare that in the past 12 months neither they nor members of their immediate families have had financial relationships with the manufacturers of goods or services discussed in this activity.

Faculty Bios Lee Ralph, MD, completed his medical degree at the Virginia Commonwealth University School of Medicine and completed his residency and fellowship at University of California, San Diego. He is Assistant Clinical Professor at the University of California, San Diego School of Medicine, and Is a family physician at the San Diego Sports Medicine and Family Health Center. He has been nominated for many years by his peers as among ”San Diego’s Top Physicians” as well as “Top Doctor in Sports Medicine.” Dr. Ralph is a member of the CAFP Board of Directors and Committee on Continuing Professional Development. Lauren M. Simon, MD, completed her medical degree at Hahnemann University School of Medicine (now known as Drexel College of Medicine) and did her internship and residency at Loma Linda University School of Medicine. She also completed a Kaiser Permanente Sports Medicine fellowship and a Masters in Public Health from Loma Linda University School of Medicine with an emphasis on health promotion and health education. Dr. Simon is board certified in family medicine, adolescent medicine, and sports medicine. She serves as a team physician for University of California-Riverside, University of Redlands, and Redlands High School. Dr. Simon is associate professor at Loma Linda University School of Medicine. Dr. Simon has achieved recognition in the NCQA Physician Practice Connections – PatientCentered Medical Home. Dr. Simon is an associate program director of Primary Care Sports Medicine at Loma Linda University, and serves on the CAFP Board of Directors as District Director for District V and as President for Riverside-San Bernardino County Chapter. Dr. Bazzo is a graduate of Rosalind Franklin University of Health Sciences, the Chicago Medical School, and completed both his family medicine residency and sports medicine fellowships at UC San Diego. Dr. Bazzo is currently faculty at UCSD, teaching medical students and residents, and runs the PACE program. Dr. Bazzo is a past president of the San Diego chapter of CAFP, and a member of the CAFP’s Committee on Continuing Professional Development. Not only is he a frequent faculty member at CAFP and AAFP meetings, Dr Bazzo has been selected by his peers as one of San Diego’s Physicians of Exceptional Excellence several years in a row, nominated in 2008 and 2009 for Kaiser Excellence in Teaching Award third year class, and “Volunteer of the Year” for the San Diego Performing Arts Council, Star Award. He has received grants from the National Institute of Health, Science Education Partnership Award (SEPA) for his work as Co-Investigator. Dr. Bazzo has authored journal articles in Urgent Care about migraines, presports participation examinations, and musculoskeletal topics among his myriad interests in primary care.

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Head Trauma: From Concussions to Traumatic Brain Injury An interactive discussion with: Lee P. Ralph, MD David E. Bazzo, MD Lauren Simon, MD

May 2011

California Academy of Family Physicians

S U N D A Y

2011 | California Academy of Family Physicians

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2011 | California Academy of Family Physicians

Definition of Mild Traumatic Brain Injury A dysfunction of brain metabolism rather than a structural injury or damage to the brain Mild traumatic brain injury(MTBI) is controversially used interchangeably with the term concussion

US Dept. HHS, CDC, Heads Up: Facts for Physicians about MTBI, 2006

Definition 



Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces May be caused by a direct blow to the head, face, neck or body with an “impulsive” force transmitted to the head Results in rapid onset of short‐lived impairment of neurologic function that resolves spontaneously

3rd International conference on concussion in sports, Zurich, Nov. 2008

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Definition 

 

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Symptoms largely reflect a functional disturbance rather than a structural injury May or may not involve loss of consciousness Resolution of symptoms typically follows a sequential course but in some cases symptoms may be prolonged No abnormality on standard structural neuroimaging studies 3rd International Conference on concussion in sports, Zurich, Nov. 2008

Glasgow Coma Scale 



Most common system for classifying Traumatic Brain Injury (TBI) severity Score based upon verbal, motor and eye opening reactions to stimuli

S U N D A Y

2011 | California Academy of Family Physicians

Glasgow Coma Scale

2011 | California Academy of Family Physicians

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Traumatic Brain Injury (TBI) 

  

A broad term used to describe a spectrum of brain injuries resulting from trauma Severe TBI : GSC = 3‐8 Moderate TBI : GSC = 9‐12 Mild TBI : GSC = 13‐15

2011 | California Academy of Family Physicians

Signs and Symptoms of Acute Concussion    

Physical Cognitive Emotional Sleep Related

3rd International Conference on concussion in sports, Zurich, Nov. 2008

Physical Signs and Symptoms of Acute Concussion       

Headache Nausea/vomiting Balance problems Visual problems Fatigue Sensitivity to light or noise “Dazed” or “Stunned”

US Dept. HHS, CDC, Heads Up: Facts for Physicians About MTBI, 2006

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Cognitive Signs and Symptoms of Acute Concussion      

Feeling mentally “foggy” or slowed down Difficulty concentrating or remembering Forgetful of recent information (amnesia) Confused about recent events Answers questions slowly Repeats questions(perseverates)

US Dept. HHS, CDC, Heads Up: Facts for Physicians About MTBI, 2006

Emotional Signs and Symptoms of Acute Concussion    

Irritability Sadness Hyper‐emotional Nervousness

S U N D A Y

US Dept. HHS, CDC, Heads Up: Facts for Physicians About MTBI, 2006

Sleep Related Signs and Symptoms of Acute Concussion   

Drowsiness Hyper‐ or Hyposomnolence Difficulty falling asleep

US Dept. HHS, CDC, Heads Up: Facts for Physicians About MTBI, 2006

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Epidemiology: Magnitude of MTBI 



1.4 million traumatic brain injuries(deaths, hospitalizations, ER visits) occur yearly 75‐90% of these are concussions or other forms of MTBI(bleeds, contusions, blast injuries, minor skull fractures)

US Dept. HHS, CDC, Heads Up: Facts for Physicians About MTBI, 2006

Epidemiology 



1.6‐3.8 million sports and recreation related TBIs occur in the U.S. each year Most of these injuries are not treated in a hospital or emergency room

US Dept. HHS, CDC, Heads Up: Facts for Physicians About MTBI, 2006

Epidemiology in Children and Adolescents 



500,000 ER visits/year resulting in 95,000 hospitalizations/year 90% of these are “minor,” but 7,000 children die each year of head trauma and 29,000 cases of permanent disability yearly Main causes: MVAs, falls, assaults, bike accidents and trauma related to sports

Symptom Checker, Harvard Medical School, Harvard Health Decision Guide, 2007

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Office Tools and Techniques for Evaluation 

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Thorough history: signs, symptoms, previous head injuries Head and neck exam Focused neurological exam (including mental status, gait and balance assessment) – Balance Error Scoring System (BESS) SAC (Standardized Assessment of Concussion) or SCAT2( Sport Concussion Assessment Tool) 2011 | California Academy of Family Physicians

Evaluation 

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SAC (Standardized Assessment of Concussion) or SCAT2 (Sport Concussion Assessment Tool) Standard orientation questions are unreliable (person, place and time) Serial monitoring for first few hours – observing carefully for signs of deterioration

S U N D A Y

2011 | California Academy of Family Physicians

Return to Play Guidelines 

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Any player with signs of concussion should be removed from play Player should be closely monitored for the next few hours Medical evaluation with frequent follow up Return to play follows a medically supervised stepwise process

2011 | California Academy of Family Physicians

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Return to Play Guidelines  

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“When in doubt, sit them out” New California Interscholastic Federation(CIF) guideline requires a licensed physician(MD or DO) to provide written release prior to returning to play Zurich Guidelines (November 2008) provide a structured return to play protocol Athletes must be asymptomatic at rest, with cognition and when physically active before returning to play 2011 | California Academy of Family Physicians

Prevention    

Headgear – “risk compensation” Mouth guards Rule Changes Education – public, players, athletic trainers, coaches, parents

2011 | California Academy of Family Physicians

Neuroimaging 

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In general, structural imaging provides little benefit in concussion evaluation Should be used if suspicion of an intracerebral structural lesion exists: i.e., prolonged disturbance of consciousness, focal neurologic deficit or worsening symptoms Functional MRI demonstrates activation patterns that correlate with symptom severity and recovery

2011 | California Academy of Family Physicians

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Neuroimaging 

 

Non‐contrast CT – test of choice for intracranial hemorrhage during the first 24‐48 hours after injury CT best modality for detecting skull fractures After 48 hours MRI may be more appropriate(able to detect cerebral contusions, petechial hemorrhage and white matter lesions)

2011 | California Academy of Family Physicians

Neuroimaging 

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Functional Imaging (Functional MRI) – can measure metabolic and hemodynamic changes in the brain Other functional modalities such as PET, MRS, SPECT and MEG (Magnetic Encephalogram) are promising and still being developed

S U N D A Y

2011 | California Academy of Family Physicians

Intracerebral Bleeding   

Contusion and Intracerebral Hemorrhage Epidural Hematoma Subdural Hematoma

2011 | California Academy of Family Physicians

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Contusion and Intracerebral Bleed 

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Contusion to the brain with hemorrhage and surrounding edema Focal neurologic deficits usually present Profound neurological deficits such as obtundation or coma may be seen

2011 | California Academy of Family Physicians

Epidural Hematoma 

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Acute collection of blood between the inner table of the skull and the dura Usually associated with a fracture that lacerates meningeal artery Classic presentation: LOC with head injury followed by “lucid interval,” then rapid mental status deterioration

2011 | California Academy of Family Physicians

Subdural Hematoma 

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A collection of venous blood between the dura mater and the arachnoid Results from tears in the bridging veins that extend from subarachnoid space to dural venous sinuses Common mechanism is sudden acceleration‐ deceleration More common in those with cerebral atrophy(elderly or alcoholics) 2011 | California Academy of Family Physicians

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Neuropsychological Testing 

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 

Measures reaction time, memory and other neurocognitive functions Useful because cognitive recovery will usually be delayed until after clinical symptom resolution Can assist with return to play clinical decision making Done when the athlete is asymptomatic Can be used for pre‐participation screening with high risk sports 2011 | California Academy of Family Physicians

Neuropsychological Testing 

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Computer based – ImPACT, CogSport, ANAM, Headminder Written based – Usually requires a neuropsychologist to interpret and administer Several other types in development and available, e.g. – King‐Devick test, Military Acute Concussion Evaluation (MACE)

S U N D A Y

2011 | California Academy of Family Physicians

Treatment    

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Rest Rest More rest – both physical and cognitive Education – patients/players, coaches, parents and teachers Most concussions resolve (80‐90%) within a relatively short time period (7‐10 days)

2011 | California Academy of Family Physicians

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Patient Instructions

SCAT 2

Chronic Traumatic Brain Injury 

 

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Post‐Concussion Syndrome – small number usually 10‐20% of all concussions Second Impact Syndrome (SIS) – controversial Chronic Traumatic Encephalopathy (CTE) – NFL Football Brain Registry – also referred to as “dementia pugilistica,” some cases can mimic ALS Long term psychiatric effects – much more significant than previously believed 2011 | California Academy of Family Physicians

Summary 



MTBI/Concussions are a common everyday occurrence frequently seen by primary care providers – “Take it seriously...bruising the brain is a big deal” (Dr. Dave Baron 1/5/11) Guidelines and tools are available to help in the management of these cases There is a tremendous need to improve our knowledge base and understanding of these injuries Whenever possible...“Play it safer” 2011 | California Academy of Family Physicians

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Questions? Thank you.

2011/California Academy of Family Physicians

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SAMs Group #2: Sunday, May 15, 12:30-5:30 pm Health Behavior

Michelle Quiogue, MD Family Medicine Kaiser Bakersfield Bakersfield, CA

Activity Description Using a group learning approach, the registrants for this session will complete Part 1 of the Health Behavior SAMs, and will have the opportunity to begin Part 2 patient simulation.

Learning Objectives Upon completion of Part A, the physician will be able to demonstrate knowledge in:

1. Pathophysiology

3. Acute management

2. Diagnosis

4. Chronic management 5. Rehabilitation 6. Prevention

Measures of success include:

1. 80% of questions correctly answered within each competency area

3. Upon successful completion, progression to the simulation component (Part B)

2. 80% successful completion rate for questions overall

Upon completion of Part B, the physician will be able to demonstrate skill in:

7. Taking a history for a cerebrovascular disease case

9. Performing a laboratory evaluation for a cerebrovascular disease case

8. Performing a physical examination for a cerebrovascular disease case 10. Managing care for a cerebrovascular disease case

Measures of success include: Carrying out at least 50% of the performance actions/interventions, as specified by the above guidelines, in taking a history, performing a physical examination, performing a laboratory evaluation, and managing care for a cerebrovascular disease case, during the simulated clinical encounter.

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Faculty Disclosures Dr. Quiogue declares that in the past 12 months neither she nor members of her immediate family have had financial relationships with the manufacturers of goods or services discussed in this activity.

Faculty Bio Michelle Quiogue, MD is a board certified family physician. She graduated from Brown Universityâ&#x20AC;&#x2122;s Program in Liberal Medical Education and completed her family medicine residency at Kaiser Permanente Los Angeles Medical Center. Dr. Quiogue moved to Bakersfield to fulfill a National Health Service Corps Scholarship with Clinica Sierra Vista Community Health Centers. In 2007, she joined the Southern Californian Permanente Medical Group in Bakersfield, CA. Dr. Quiogue served as Co-Chair of the CAFP Committee on Continuing Professional Development before becoming Editor of the California Family Physician magazine in 2010. In addition to her role as the President of the Kern County Chapter, Dr. Quiogue has represented her local chapter at the Congress of Delegates and attended the AAFP National Conference of Special Constituencies as a Women's Delegate for California. Handouts will be provided to registrants in the Conference Theater Room.

S U N D A Y

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Session #12: Sunday, May 15, 1:45-2:45 pm 2 Minutes, 2 Slides, 2 Questions David Bazzo, MD, and a cast of family physician challengers Clinical Professor of Family Medicine University of California, San Diego PACE/C-CHIP/QICM Office San Diego, CA

Faculty Disclosures David Bazzo, MD declares that in the past 12 months neither he nor members of his immediate family have had financial relationships with the manufacturers of goods or services discussed in this activity.

Activity Description Dr. Bazzo and his challengers will offer several case presentations, clinical pearls and medical advances that will be reviewed and discussed with the audience in an interactive educational format. Each presenter will have two minutes to present their information using wo PowerPoint slides. At the end of the presentation, the audience will be allowed to ask two questions of the presenter. Each case will be presented by a different speaker with the audience voting on the best presentation at the end of the session.

Learning Objectives

1. Be able to identify specific clinical presentations of interesting cases that present to a family physician. 2. Be able to expand their recognition of common symptoms that lead to unusual diagnoses. 3. Be able to describe the clinical pearls that are presented in the interactive format

4. Be able to describe medical advances related to interesting cases that are presented.

Faculty Bio Dr. Bazzo is a graduate of Rosalind Franklin University of Health Sciences, the Chicago Medical School, and completed both his family medicine residency and sports medicine fellowships at UC San Diego. Dr. Bazzo is currently faculty at UCSD, teaching medical students and residents, and runs the PACE program. Dr. Bazzo is a past president of the San Diego chapter of CAFP, and a member of the CAFP’s Committee on Continuing Professional Development. Not only is he a frequent faculty member at CAFP and AAFP meetings, Dr Bazzo has been selected by his peers as one of San Diego’s Physicians of Exceptional Excellence several years in a row, nominated in 2008 and 2009 for Kaiser Excellence in Teaching Award third year class, and “Volunteer of the Year” for the San Diego Performing Arts Council, Star Award. He has received grants from the National Institute of Health, Science Education Partnership Award (SEPA) for his work as Co-Investigator. Dr. Bazzo has authored journal articles in Urgent Care about migraines, presports participation examinations, and musculoskeletal topics among his myriad interests in primary care.

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Two HIT Workshops:

#1 – Sunday, May 15, 2:30-3:30 pm

Meaningful Use 101: I Need to Register and Eligibility and Payment Considerations

Elise R. Singer, MD, MBA, CAQ Chief Medical Officer California Health Information Partnership and Services Organization (CalHIPSO) Clinical Instructor University of California San Francisco Lakeshore Center

Activity Description Dr. Singer will use an interactive format with assistance from volunteer physician panel to assist participants in the registration process for meaningful use.

Learning Objectives

1. Explain the intent of certified electronic health records technology legislation and how it enhances patient care/outcomes 2. List the eligibility criteria to apply for MU funding

3. Describe how to apply for MU funding including designated timelines 4. Explain Medicare payment incentives

Faculty Disclosure Dr. Singer is a Co-Founder and on the Board of Advisers for Doximity of Palo Alto.

Faculty Bio Elise R. Singer, MD, MBA, CAQ, completed her medical degree at UMDNJ-Robert Wood Johnson Medical School, completed her residency in Valley Health Care in Washington, and her fellowship in Geriatrics at Thomas Jefferson University Hospital. She completed her MBA at the University of California, Berkeley Walter Haas School of Business. Dr. Singer was previously Director of Ambulatory Informatics at Cooper University Hospital in New Jersey and a board member of the Camden Coalition of Healthcare Providers. She was previously a Clinical Assistant Professor at Robert Wood Johnson Medical School and is currently a Clinical Instructor at the University of California, San Francisco Lakeshore Center, precepting fourth-year medical students in family medicine. Dr. Singer has been a Delegate from CAFP’s Alameda-Contra Costa Chapter.

Support This activity is presented as a part of CAFP’s work with Cal HIPSO, and the unrestricted educational grant from The Physicians Foundation.

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S U N D A Y

Two HIT Workshops

#2 – Sunday, May 15, 4:00-5:00 pm

Meaningful Use 201: How to Understand the Measures and Action Plan

Activity Description This session, for more advanced participants, will work through the stages of meaningful use, including categories and function, testing, and action planning.

Learning Objectives

1. Describe the stages of meaningful use

3. Explain the test to implementing “information exchange”

2. Explain and describe the categories and functions of core objectives 4. Create an action plan for MU registration and application

Faculty Disclosure Dr. Singer is a Co-Founder and on the Board of Advisers for Doximity of Palo Alto.

Support This activity is presented as a part of CAFP’s work with Cal HIPSO, and the unrestricted educational grant from The Physicians Foundation.

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