Best Practices for the Medical Management of Overweight and Obese Patients

Last month we looked at surgical interventions for patients with morbid obesity. This month, we turn to the much more common problem of how to medically manage patients who are overweight or obese.

Case Study: On the same day that you saw Naomi, who expressed an interest in bariatric surgery to treat her morbid obesity, you also saw Lauren. Lauren is a 30-year-old woman who recently experienced a series of life stressors, including the serious illness of a parent and the loss of a long-term romantic relationship. Also during the past year, she left her job and moved back to the town where she had grown up in order to take her of her sick mother. Thankfully, Lauren’s mother is improving, but the past few months have taken a physical and emotional toll on Lauren. More specifically, she has gained 50 lbs. Lauren says,

“I have never weighed this much in my life. How do I lose all of this extra weight?”

As a first step, you calculate her body mass index (BMI). Lauren is 5 feet 4 inches tall and weighs 165 lbs. To calculate her BMI, you can either use an online calculator or convert her height to meters and weight to kilograms. The formula to calculate BMI is

BMI = weight (in kg)/(height (in m))2.

Using this equation, you find that Lauren’s BMI is 28.3 kg/m2, placing her in the overweight (but not obese) range for BMI. Now you should review her options for medical management. These options include lifestyle modifications such as behavioral changes, improved diet, and increased exercise. They may also include medications currently approved for weight loss in the United States.

What do you do next?

Although Lauren came to you for help with weight loss, you are not the only professional who will be involved in her care. You can refer Lauren to a vetted psychologist, nutritionist, physical trainer, and/or pharmacist for additional support.

Behavioral changes and stress management play critical roles in helping patients lose weight and keep weight off. You encourage Lauren to begin counseling to better understand how her eating is impacted by stress. If she is amenable to group support, support systems can be found through commercial programs (like Weight Watchers), religious organizations, the local YMCA, and community overeating support groups.

Despite the controversies and hard-line stances, there are numerous high-quality diets that are effective for weight loss and health long-term. The key component of any diet is decreased caloric intake. Safe, effective diets can be vegetarian, low-fat, low-carbohydrate, or protein-heavy/low glycemic index diets. A referral to a nutritionist would be a great idea. Similarly, you should encourage Lauren to start exercising, and work her way up to 150 minutes of exercise a week. You have already completed a physical examination, and she is in good cardiovascular health. Lauren does not have any co-morbid conditions, so you give her the green light to start an exercise program.

What about pharmaceutical options for treating obese and overweight patients?

In the United States, the Food and Drug Administration has approved five medications for long-term weight loss management: orlistat, lorcaserin, phentermine/topiramate, naltrexone/bupropion, and liraglutide. Indications for prescribing these medications are a BMI over 30 kg/m2 or a BMI over 27 kg/m2 with the presence of certain co-morbid conditions (including diabetes, hypertension, etc.). These medications are prescribed for use in conjunction with lifestyle changes.

Orlistat works by inhibiting pancreatic lipase, leading to the excretion of 30% of dietary fat in stool. Not surprisingly, its side-effects include gastrointestinal distress and decreased absorption of fat-soluble vitamins.

The remaining four medications work by regulating appetite. Lorcaserin is a selective serotonin 2C receptor agonist. Side-effects include nausea, headache, dizziness, constipation and hypoglycemia in diabetic patients. These medications are contraindicated during pregnancy.

Phentermine increases norepinephrine to suppress appetite while the mechanism of how topiramate produces weight loss is not well-understood. Side-effects include insomnia, paresthesias, dizziness, nausea and constipation.

Naltrexone/bupropion side-effects are headache, nausea/vomiting, diarrhea/constipation, and headache. Bupropion inhibits dopamine and norepinephrine reuptake, while naltrexone is an opioid receptor agonist.

Lastly, liraglutide is an injectable that works as a glucagon-like peptide-1 (GLP-1) receptor agonist. However, there are significant risks of medullary thyroid carcinoma and acute pancreatitis associated with this medication.

What sort of medical management would you recommend for Lauren?

Lauren should start with behavioral support, including psychological counseling, nutritional evaluation, and exercise. At this time, she is not a candidate for long-term pharmaceutical intervention because her BMI is less than 30 kg/m2 and she lacks co-morbidities.

Visit our Patient Education page, which includes an Obesity Shared Decision Making Tool called PEPtalk Weight Management. This weight management tool is designed to promote wellness and self-management through shared decision-making between patients and clinicians. It provides patients with the knowledge, skills, and confidence to actively participate with their clinicians when making decisions that can improve their health and healthcare.

References:

Bray GA, Frühbeck G, Ryan DH, Wilding JP. Management of obesity. Lancet. 2016;387(10031):1947-56.

Patel D. Pharmacotherapy for the management of obesity. Metab Clin Exp. 2015;64(11):1376-85.

Dr. V. Silverstein
Durham, NC

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Dyslipidemia and Diabetes

Dyslipidemia and Diabetes: Evolving Guidelines, Treatments, Goals

CME Information

1

Program Overview

This activity is part of the Joslin Diabetes Center Virtual Grand Rounds Series. This session will focus on understanding and interpreting the new lipid guidelines and utilizing new lipid treatments in this context to establish appropriate treatments for a variety of dyslipidemic syndromes.

Accreditation/Designation Statements

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Primary Care Network and PlatformQ Health Education, LLC. Primary Care Network is accredited by the ACCME to provide continuing medical education for physicians.

Live Online Activity – Wednesday, March 29, 2017 from 12:00 PM – 1:00 PM EST.

Primary Care Network designates this live activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Online On-Demand Enduring Material

Primary Care Network designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Enduring Material Date of Release/Expiration

The enduring material will be available from March 29, 2017 – September 29, 2017.


Learning Objectives

At the conclusion of this activity, participants will be able to:

  • Implement key elements and major changes in the updated treatment guidelines for dyslipidemia with a focus on how they would apply to treatment design for dyslipidemia and diabetes
  • Identify when newer non-statin drug therapies may be indicated for patients with high lipid-related CVD risk despite maximum tolerated statin therapy
  • Delineate the pharmacology, approved indications, and potential barriers to overcome ineffective use of PCSK9 inhibitors in patients at high risk for CVD events

Jointly provided by Primary Care Network, PlatformQ Health Education, LLC and its collaborating partner Joslin Diabetes Center.

PCN_web joslin_diabetes_center_logo

 

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Participant will need to initially complete a short registration form with Diabetes Series Live to participate in this activity. Future participation in Diabetes Series Live activities will allow you to skip the registration process and only require you to log-in.

Published March 17, 2017

 

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Reducing Hypoglycemia

Treatment of Type 2 Diabetes with Special Consideration to Reduce Hypoglycemia

 


Learning Objectives

After participating in this educational activity, participants should be better able to:

  1. Apply strategies to individualize glycemic targets in patients with type 2 diabetes
  2. Discuss the limitations of frequently used conventional therapies for the treatment of patients with type 2 diabetes
  3. Outline the risk factors and clinical consequences of hypoglycemia
  4. Implement strategies to minimize hypoglycemia risk in the treatment of patients with type 2 diabetes


Overview

This educational activity will focus on the optimal management of patients with type 2 diabetes while minimizing hypoglycemia risk. Specifically, this program will help clinicians identify patients who are at an increased risk for hypoglycemia and will highlight the limitations of frequently used conventional therapies. There will also be discussion on how to optimize therapy while minimizing the risk of hypoglycemia in patients with type 2 diabetes.

 

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This activity has expired and is no longer available for CME; however, we hope you still enjoy the education.

Published on March 10, 2015

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Understanding of Obesity

Neurobiological Understanding of Obesity: New Treatment Guidelines and Patient-Centered Approach


Learning Objectives

After participating in this educational activity, participants should be better able to:

  1. Screen for risk factors of obesity and diagnose obesity as a disease early in its evolution
  2. Prescribe pharmacological intervention for obesity based on the neurobiology and pathophysiology of the disease following the National Heart, Lung and Blood Institute (NHLBI) guidelines
  3. Describe the safety and efficacy studies of various agents and create awareness of post marketing and long term pharmacovigilance studies to assess long term risks
  4. Focus on obesity as disease and provide communication strategies to build ongoing collaborative relationships with obese patients


Overview

Obesity has reached epidemic proportions for both children and adults and has become a major public health problem. Two-thirds of adults are overweight; one-third of them are obese. Obesity is associated with significant health risks and comorbidities including diabetes, metabolic syndrome, cancer, heart disease, depression, sleep apnea, osteoarthritis, and others.

Lifestyle interventions focused on diet, physical activity, and behavioral therapy are essential components to treating obesity and should be incorporated throughout the continuum of care. Some patients will successfully achieve weight loss with these efforts alone; however it is well documented that long-term weight loss and maintenance is difficult to achieve. When “first-line” interventions alone have not succeeded, the National Heart Lung and Blood Institute (NHLBI) guidelines recommend pharmacological intervention as an option.

This CME article will present the clinical realities of obesity encouraging an open provider/patient relationship that enhances care, allowing for discussions on goals, adherence, barriers, and expectations.

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This activity has expired and is no longer available for CME; however, we hope you still enjoy the education.

Published on December 30, 2014

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Advance Directives

Preparing for Death with Dignity via Advance Directives

 

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Have you ever thought about how you are going to die? Will you die comfortably or tragically? Will death overtake you suddenly or perhaps be a slow, painful process? The uncertainties surrounding death abound, but one thing is for sure, it is inevitable. The subject of death can be an uncomfortable one for many people, for various reasons. Yet in medicine, death and dying are commonly encountered occurrences, particularly when dealing with patients within the geriatric population.

However, many elderly adults and their loved ones may not have given serious consideration to how their lives may end and how they will manage and react when that time comes. They are not prepared for the inevitable. But, preparation is just the thing they need, in order to make peace with death and dying. Advance directives are the key to being prepared. They encourage people to think about their own death and how to take some control over the process. For patients who want to prepare and learn more about developing an advance directive, they seek guidance from their healthcare provider. For this reason, healthcare providers need to be knowledgeable about advance directives and be able to advise their patients. The Agency for Healthcare Research and Quality (AHRQ) reported that only 12% of patients who had an advance directive involved their physician in its creation and 65% to 76% of providers were unaware that their patients had advance directives.[1]

For the patient that does not yet hold an advance directive, particularly if that patient is elderly, addressing this topic at the healthcare visit becomes particularly vital. As people age, their risk for developing any number of chronic diseases greatly increases. In fact, the AHRQ has determined that approximately 80% to 85% of people aged 65 and beyond, will eventually become ill and meet their demise related to a chronic illness. In particular, cerebrovascular and cardiovascular diseases, Alzheimer’s disease, diabetes, renal disease and obstructive pulmonary disease are the main culprits, as each lends itself to progressive declines in physiological and mental health and function over less predictable lengths of time. There can also be occasional exacerbations that may require hospital admission. [1] Furthermore, according to Dr. Peter Saul, in his presentation of “Dying in the 21st Century,” there are four main categories through which people face death. Because of these, advance directives are not only necessary, but should become a health initiative priority. They include: death related to frailty, organ failure in the case of chronic disease, terminal illness, and sudden (unexpected) death. [2]

What exactly is an advance directive? An advance directive consists of several components that document or help people to express their wishes regarding treatment actions to be taken if they were to become critically ill, involved in a serious accident, in a coma, or become severely cognitively impaired and therefore unable to express these wishes for themselves. The concept of the advance directive was created as a provision of the Omnibus Budget Reconciliation Act proposed in November 1990, in order to give patients a choice in the medical treatments they receive. Also, through the Patient Self-Determination Act passed by Congress in 1991, patients were empowered to become active participants in medical decisions “affecting the condition and length of their life,” including being able to accept or reject treatments and create an advance directive. [3, 4] The advance directive is formulated by patients, often in discussion with their loved ones, and/or healthcare provider, and/or pastor. Advance directive components include the living will, medical durable power of attorney, do-not-resuscitate (DNR) orders, Protective Medical Decisions Document (PMDD), and the Physician Orders for Life Sustaining Treatment (POLST).

The living will also known as a healthcare directive or declaration, is a document that contains the patients’ predetermined wishes regarding the treatment modalities and measures to sustain life they would want and expect for themselves, in any serious health situation where they were unable to express these needs themselves. [5] For example, a patient with a neurological disease may pre-express in the living will that if he/she were to one day end up in coma, he/she would not want to be given artificial nutrition or hydration via feeding tubes. Further, in this document, patients could state their wishes regarding the use of mechanical respiration ventilators, hemodialysis, and in the event of death, even donation of their organs. [5] The living will is initiated by the patient’s attending physician in the event of three concurrent occurrences: the patient has lost the ability to make medical decisions, the patient must have an end-stage illness or injury from which the person will most likely not recover, and that artificially sustaining the patient’s life will hinder the ability to die naturally. [6]

The medical or healthcare power of attorney (POA) is a document that identifies one particular person (such as a spouse or family member or close friend), named by the patient, to be the “agent” or “proxy” (also known as a “surrogate” or “representative”) to make decisions regarding treatment modalities, in the event that the person is seriously incapacitated and cannot speak for himself. The decision to choose an agent should be made with deliberation and thought, as the chosen one must be able to convey and abide by the patient’s predetermined wishes and make choices for the patient in any unforeseen situation. If this were to happen, the agent would then be able to make unbiased decisions, on the patient’s behalf, based on knowledge of the patient’s values and wishes. [5] Additionally, a person may consider a second or even a third agent in the event the first one named is not available or is unable to make the necessary decisions. [6]deathbed

The PMDD is a written form of the durable power of attorney for healthcare (DPOA). Available through the Patients’ Rights Council, its purpose is similar to that of the medical POA. However, the PMDD goes one step beyond, by providing patients with increased protection (in the event of their decision making incapacity) against an agent who decides to terminate their (patients’) lives directly and intentionally, via assisted suicide or euthanasia. Besides the primary agent, alternative representing agents may be named in the PMDD, as well. [7]

The DNR order is written by a physician. It states the patients’ wishes as to whether or not they would want cardiopulmonary resuscitation (CPR) in the event they sustained cardiac or pulmonary arrest. The DNR may exist in two forms; one that addresses the CPR situation within the hospital setting and another for pre-hospital CPR situations, such as at home or in a nursing facility. [8]

Finally, the POLST is a standardized form initiated by physicians with their patients, in order to document the patients’ wishes regarding certain types of life sustaining treatments they desire or do not wish to have when their health condition is serious and they are unable to express what they want (at that time). Signed by both the physician and patient, it becomes part of the medical record, thereby making it portable and valid in any locality that patients may be in, even if they were to experience a serious health crisis when away from home. [9]

When a patient without an advance directive is hospitalized with a serious medical condition and unable to communicate, physicians must delegate that responsibility to whomever they deem appropriate to make choices on behalf of the patient. Usually this is the patient’s next of kin. Given that physicians are often unaware of patients’ wishes or who their choice of agent would have been, the doctors will make that decision for the patients. But later, if the doctors do not agree with the choices made by the agent whom they have chosen, they may then feel free to choose another. [10] This whole situation can be turned around by having an advance directive ready and available. Then, if doctors are in disagreement with the patients’ or their agent’s decisions, under federal law, doctors are required to inform the patients or their agent of that in advance at time of potential admission. In states such as Texas with an even more stringent law, doctors/facilities must render care even if they consider it to be “futile care” until provisions can be made to transfer the patient to another facility or physician who will honor the patient or agent’s choices. [10]

The responsibility for the development of a patient’s advance directive lies not only with the patient, but ultimately with the patients’ healthcare provider, as this is a very important component of the patient’s comprehensive health care. In preparation for addressing this issue with the provider patients should contemplate and discuss various items with their trusted loved ones including: [6]

  • Their attitudes towards life, including activities that bring them joy and situations they fear
  • Their attitudes about potentially losing control and independence
  • How their attitudes may be influenced by religious beliefs
  • Their attitudes towards being seriously ill or injured
  • Their attitudes regarding overall health, being ill, dying, and death
  • Their understanding of the choices for medical treatment, in the event of serious illness or injury
  • Their feelings about being unable to communicate their wishes should they become brain dead, go into a perpetual coma, or become terminally ill
  • Their feelings about having healthcare providers make treatment decisions independent of the wishes of patients
  • Informing their loved ones of their expectations for treatment at the end of life
  • Informing loved ones of their fears and concerns regarding treatments under certain circumstances
  • Knowing how their loved ones would feel about the patient’s advance directive choices and if they could respect them
  • Selecting their primary medical POA and alternates based upon the knowledge that their chosen agents clearly understand the reasons behind the patient’s beliefs and decisions and could be trusted to abide by their wishes
  • Determining if their chosen agents would be willing to accept this responsibility
  • Ensuring that their agents understand the patient’s current health conditions, how these conditions could negatively progress, treatment options available,  adverse effects of these treatments, and prognosis with and without treatment including measures that may be used to prolong and sustain life
  • Their idea of what “quality of life” means to them
  • Their idea of what “dying with dignity” and “no heroic measures” means to them
  • Their thoughts about pain and their expectations regarding how their pain should be managed
  • Ensuring that they are informed about pain management options and effects
  • Their thoughts about life after death and how that thought may influence their advance directive choices
  • Discovering if they have any obstacles discussing issues regarding advance directives
  • Being aware of both their own and their loved ones’ understanding of the purpose of an advance directive

Healthcare providers, on the other hand, need to prepare to discuss advance directives with their patients by first being aware of their own feelings regarding the issues involved. Next, they must increase their own comfort level when discussing this topic with their patients. According to the results of patient surveys regarding advance directives, “most adults would prefer to discuss advance directives while they are well, preferably with a doctor who has known them over time…they look to their doctors to initiate the discussion”. [11] Yet, only approximately 15% to 25% of adults have actually completed advanced directives usually after hospitalization with a serious illness. [11] Further, a study of outpatients aged 65 years and older has determined that “a doctor’s inquiry increased two- to three-fold the chances that individuals would have an advance directive on file with their health plan”. [11]

Drs. Zwieg and Mehr from the University of Missouri-Columbia School of Medicine recommend that end-of-life care discussions between healthcare providers, their patients, and their families should consist of four main components. First, patient preferences should be determined. This could include their thoughts on treatments they want and those that they don’t. Second, prognosis for disease states that patients are experiencing should be discussed. This could include thoughts on how much time certain treatments or procedures would buy patients, as well as how these may affect their quality of life. Third, the goals of providing such treatments and procedures should be addressed. This could include knowing not only the outcomes hoping to be achieved, but also informing patients of the benefits, risks and even the financial cost involved. Lastly, a management plan should be developed keeping patients’ goals in the forefront. This could include advance directives that permit both broad and specific decisions to be made in various circumstances of serious illness and/or injury and death. [12]

Overall, it is most important for healthcare providers to be respectful and emotionally supportive of their patients’ choices. In discussing advance directives, providers must be aware of patients’ values and goals. [13] They should address any concerns, questions, and fears that patients and their families and/or agent’s may have and supply information necessary to make informed decisions.  Also, providers should keep a copy of advance directives in the patient’s medical record. Patients should be reminded to give copies to their primary agent and alternates, children, and any other people who need to know the patient’s wishes. Copies can be filed, without cost, at patients’ local hospitals. [6]

Of course, patients should be aware that they can change their advance care decisions if ever the need arises. Usually this will require destroying the original and copies of the old advance directives and replacing them with the updated ones. Living wills and medical power of attorney usually require two witnesses (one may need to be a notary) to observe the patient’s signing and dating the advance directive. [6] Patients should check their state regulations for guidance regarding the creation of advance directives (or consult the National Hospice and Palliative Care Organization’s website). [14] A lawyer is not required for this process. [5] Advance directives should be reviewed each year, dated and initialed. The original should be readily available when needed. Additionally a card stating that patients have advance directives should be kept in their wallet, in case of an emergency. [6]

Having an advance directive is a vitally important part of the healthcare plan. Healthcare providers need to make the time to address this topic with their patients. Advance directives will not only lessen their patients’ suffering and increase their peace of mind, but they will also provide a sense of autonomy and control over their death. [8] Additionally, they can take away some of the frustration, stress, confusion, guilt, and uncertainty for loved ones who are faced with the patient’s terminal situation. [15] Death and dying can be uncomfortable subjects to confront, but as healthcare providers, we must be able to do so every day. Providers may even teach by example by having an advance directive of their own. As was said by the late Dame Cicely Saunders, founder of the modern hospice movement, “You matter because you are you and you matter until the last moment of your life”. [16]


Karen Digby, BA, BSN, MS, GNP-BC, CWS

GNP Independent Contractor/Writer
Ann Arbor, Michigan

Published on November 26, 2013

 

Biosketch

Karen Digby is a nurse practitioner specializing in geriatrics. She received her training from New York University and the University of Michigan in Ann Arbor. In over ten years of practice, Karen has obtained a wealth of experience in various aspects of health care including home care, outpatient/ambulatory care, dementia care, subacute care, hospice, and assisted living and long-term care. Due to her expertise in geriatrics, Karen was selected as an item writer, by the American Nurses Credentialing Center, for the Gerontological Nurse Practitioner Board Certification Examination. She also co-authored an article on “Falls in the Elderly” in the Plastic Surgical Nursing Journal. Additionally, Karen is certified as a Wound Care Specialist through the American Academy of Wound Management.

References

  1. Kass-Bartelmes BL, Hughes R, Rutherford MK. Advance care planning: preferences for care at the end of life. Rockville (MD): Agency for Healthcare Research and Quality; 2003. Research in Action Issue #12. AHRQ Pub No. 03-0018. http://www.ahrq.gov/research/findings/factsheets/aging/endliferia/index.html
  2. Dr. Peter Saul. Dying in the 21st Century. TED Talk (TED x Newy). 2011. http://www.youtube.com/watch?feature=player_embedded&v=03h0dNZoxr8
  3. Department of Health and Human Services. Office of the Inspector General. Patient advance directives: early implementation experience. August 1993. http://oig.hhs.gov/oei/reports/oei-06-91-01130.pdf
  4. Rosen A, O’Neill J. Social work roles and opportunities in advance directives and health care decision making. National Association of Social Workers. March 1998. http://www.socialworkers.org/practice/aging/advdirct.asp
  5. Mayo Clinic. Consumer health. Living wills and advance directives for medical decisions. http://www.mayoclinic.com/health/living-wills/HA00014
  6. Advance medical directives. http://www.cpt.org/files/PP%20-%20Advance%20Directives.pdf
  7. Patients Right Council. Advance directive: protective medical decisions document. http://www.patientsrightscouncil.org/site/advance-directive-protective-medical-decisions-document/
  8. What is an advance health care directive? http://fcasocal.org/advance-directives.html
  9. Pope TM, Hexum M. Legal briefing: POLST: physician orders for life-sustaining treatment. J Clin Ethics. 2012 Winter;23(4):353-376.
  10. Marker RL. Patients Rights Council. Advance directive: protecting yourself and your family (part 2).  http://www.patientsrightscouncil.org/site/advance-directive-protecting-yourself-and-your-family-part-two/
  11. Wissow LS, Belote A, Kramer W, Compton-Phillips A, Kritzler R, Weiner JP. Promoting advance directives among elderly primary care patients. J Gen Intern Med. 2004 Sep;19(9):944-951.
  12. Zweig S, Mehr DR. Helping older patients and their families decide about end-of-life care. Missouri Medicine. 2003 Jan-Feb: 100(1): 62-28.
  13. Fischer GS, Arnold RM, Tulsky JA. Talking to the older adult about advance directives. Clin Geriatr Med. 2000 May;16(2):239-254.
  14. National Hospice and Palliative Care Organization. http://www.caringinfo.org/i4a/pages/index.cfm?pageid=1
  15. Span P. Why do we avoid advance directives? The New York Times. April 20, 2009. http://newoldage.blogs.nytimes.com/2009/04/20/why-do-we-avoid-advance-directives
  16. Clark D. Cicely Saunders: Selected writings 1958-2004. New York, NY: Oxford University Press, 2006.
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CLL Latest Advances

ASCO 2013: Making Relevant the Latest Advances for CLL

 

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Dr_Koffman_2     Dr_Wierda_2

Overview:

The world of Chronic Lymphocytic Leukemia (CLL) is constantly changing. These videos are intended to provide information and clarify a few of the important, yet very relevant, factors that affect patients with CLL, their choices, and your role as their healthcare provider.


This activity is targeted for healthcare providers with patients with CLL.

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Published on November 7, 2013

 

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Faculty Spotlight: Dr. Diamond

Merle L. Diamond, MD

President and Managing Director, Diamond Headache Clinic
Chicago, IL
www.diamondheadache.com

Dr. Merle Diamond joined the staff of the Diamond Headache Clinic in 1989 after serving as an attending physician and clinical instructor at Northwestern University Hospital in Chicago, and as an attending physician at Evanston and St. Francis Hospitals, both in Evanston, Illinois.

Dr. Diamond is currently an attending physician in Internal Medicine and Director of the Diamond Headache Inpatient Unit. She is a Clinical Assistant Professor, Department of Medicine, Rosalind Franklin University of Medicine and Science/Chicago Medical School. Also, she is a Lecturer in the Department of Medicine (Neurology), Loyola University of Chicago’s Stritch School of Medicine.

Dr. Diamond graduated with high honors from the University of Michigan, Ann Arbor, and received her medical education from Northwestern University Medical School in Chicago. She completed residencies in Emergency Medicine/Internal Medicine, at the McGaw Medical Center of Northwestern University. She received Subspecialty Certification for Headache Medicine from the United Council for Neurologic Subspecialties. She is a former fellow of the American College of Emergency Physicians and currently is a Diplomate of the American Board of Internal Medicine.

Dr. Diamond has contributed numerous articles to the medical literature and has lectured extensively on various headache subjects, particularly the treatment of headache in the emergency department, and hormones and headaches. With Dr. Glen Solomon, she co-edited Diamond and Dalessio’s Practicing Physician’s Approach to Headache, 6th Edition (1999).

Dr. Diamond is the 2017 recipient of the Lifetime Achievement Award of the National Headache Foundation. She is also the Course Director for the upcoming live CME meeting “Headache Update” being held at Walt Disney World Resort – Disney’s Grand Floridian Resort & Spa on July 13-16, 2017. For more information, please click here to view the course brochure.

“Our goal, above all, is to restore normal function. You may still have headaches, but you have to have the ability to manage your attacks when you get them, and still live your life.”

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Addressing Breast Cancer Concerns in Asymptomatic Patients

In the United States, the American Cancer Society predicts that 252,710 new cases of breast cancer will be diagnosed in 2017 and 40,610 women will die from this disease.This makes breast cancer the most common malignancy in women, second only to some skin cancers.As a result, health care providers in the primary care setting have an excellent opportunity to counsel women about breast cancer risk and prevention. In this blog posting, we will review some of the latest approaches in risk stratifying and preventing breast cancer in asymptomatic women.

Case Study: Sally is a 45 year old woman who comes to your office for her annual physical. As you complete her history and physical exam, you ask her if she has any questions or concerns about her health. She immediately tells you that her sister was diagnosed with breast cancer three months ago and that she is concerned about her own breast cancer risk.

What do you tell Sally?

As a first step, you will use a risk assessment tool to help determine if Sally is at higher, average, or lower risk of breast cancer. One of the best-known breast cancer risk assessment tools is the Gail model. This calculator uses patient age, age at first menstrual period, age at first live birth, number of first-degree relatives with breast cancer, previous breast biopsy, and race to determine patient risk of breast cancer. Sally is 45 years old, had her first period at 12 years old, does not have children, has one family member with breast cancer, no previous breast biopsies, and is African American. According to the Gail model, she has a 1.4% chance of developing breast cancer in the next five years (increased from 0.9% for all 45 year old women) and a 14.4% risk of developing breast cancer in her lifetime (up from 9.5% for all 45 year old women).

Racial disparities in mortality rates from breast cancer have been widening over the past decade, and breast cancer is now the most common cause of cancer-related death among Hispanic women, and the second most common cause of cancer death for black, white, and Asian/Pacific Islander women.3

Is there anything Sally can do to decrease her risk of breast cancer?

Evidence-based lifestyle changes that can decrease her risk of breast cancer include not smoking, limiting alcohol consumption, eating a plant-based diet, exercising at least 150 minutes a week, and maintaining a healthy weight. As her PCP, you can refer Sally for genetic screening and you may consider prescribing medications to decrease her risk of breast cancer if she is a high-risk patient. The US Preventative Task Force (USPSTF) recommends that primary care providers discuss risks and benefits of medications such as tamoxifen and raloxifene that can potentially decrease the likelihood of developing breast cancer in high-risk women. Women with genetic markers for breast cancer, including BRCA1 and BRCA2, may consider surgical intervention after speaking with their health care team.

What do you recommend Sally do to decrease her risk?

Sally is a good candidate for making lifestyle changes. You may also send her to a genetic counselor, particularly if you learn that she has additional family members who were diagnosed with breast cancer. The FDA has approved prophylactic tamoxifen for use in women over 35 years old with a five-year breast cancer risk greater than 1.67%. Sally’s five-year breast cancer risk is 1.4%, so you may want to wait to hear back from the genetic counselor before considering medical or surgical interventions.

References:

1 What are the key statistics about breast cancer? American Cancer Society website https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html. Updated January 5, 2017. Accessed March 2, 2017.

2 Breast Cancer Statistics. Centers for Disease Control website https://www.cdc.gov/cancer/breast/statistics/. Updated March 23, 2016. Accessed March 2, 2017.

3 Desantis CE, Fedewa SA, Goding sauer A, Kramer JL, Smith RA, Jemal A. Breast cancer statistics, 2015: Convergence of incidence rates between black and white women. CA Cancer J Clin. 2016;66(1):31-42.

Dr. V. Silverstein
Durham, NC

Published on 4/29/2017

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Emergency and Urgent Care Medicine: On Demand

Emergency and Urgent Care Medicine: On Demand

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Program Overview

This CME activity is designed to update primary care clinicians in rapidly changing therapeutic areas. In 2016, Continuing Education Company introduced the inaugural conference on “Emergency and Urgent Care Medicine for the Primary Care Provider” held in San Diego, CA at the Hilton San Diego Resort and Spa on October 7-9, 2016. This activity is comprised of 21 recorded video lectures from the conference, focusing on the evaluation and treatment of acute emergency conditions and best practices for use in a clinical setting. Topics include: Opioid Prescribing, Fractures, Concussions, STIs, Acute Stroke Care, Headaches, Procedures, ICD/LVAD Essentials, Febrile Seizures, Zika and more.

Urgent Care medicine involves the delivery of immediate medical care for the treatment of acute and chronic illness and injury. Practitioners providing urgent care need to be proficient in evaluating and caring for patients presenting with a broad range of acute medical problems. As a result, urgent care medicine requires clinicians to have an extensive scope of knowledge and expertise in the evaluation and treatment of acute medical conditions in all age groups.

This activity focuses on timely and practical issues involving emergency and urgent care medicine. Sessions will provide the latest evidence-based information on the evaluation and treatment of acute emergency conditions. Each session will provide best practices for use in an outpatient clinical setting.

Learning Objectives

After completing this activity, the participant should be better able to:

  1. Assess and provide patients with an accurate diagnosis and optimal care for a broad range of acute disorders seen in primary care
  2. Recognize the role of the primary care clinician in the management of acute disorders
  3. Utilize current advances in the diagnosis and treatment of acute disorders, using whenever possible, an evidence-based approach
  4. Delineate which patients require immediate hospitalization and additional care and those that can be successfully managed as outpatients

Accreditation

AMA PRA Category 1 Credits™: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Primary Care Network (PCN) and Continuing Education Company, Inc. Primary Care Network is accredited by the ACCME to provide continuing medical education for physicians.

Primary Care Network designates this enduring material for a maximum of 15 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM MOC: Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 15 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Please allow 6-8 weeks for your MOC points to appear on your ABIM records.

AAPA: AAPA accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 15 hours of Category 1 credit for completing this activity.

AANPCP: The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts AMA PRA Category 1 Credit™ from organizations accredited by the ACCME.

 

Jointly provided by Primary Care Network and Continuing Education Company.

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click-here

 

Participant will be leaving Primary Issues and completing this activity on the hosts website.

Click on the link for more detailed information on course content, faculty, etc.

 

 

Published March 21, 2017

 

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Primary Care Medicine: On Demand

Primary Care Medicine: On Demand

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Program Overview

This course features 20 sessions designed to update primary care clinicians in rapidly changing therapeutic areas. The emphasis is on practical and useful information for clinical practice. Topics include: Cardiology, Diabetes, Endocrinology, Gastroenterology, Hepatology, Infectious Disease, Nephrology, Psychiatry, Pulmonology, Rheumatology, and Women’s Health.

This CME activity is comprised of various recorded video lectures from Continuing Education Company conferences that took place between May and July of 2016.

Learning Objectives

After completing this activity, the participant should be better able to:

  1. Assess and provide patients with an accurate diagnosis and optimal care for a broad range of disorders seen in primary care.
  2. Utilize current guidelines in the diagnosis and management of commonly encountered therapeutic issues.
  3. Formulate comprehensive evidence-based interventions and treatment strategies that will lead to the reduction of modifiable risk factors and improved long term outcomes.

Accreditation

AMA PRA Category 1 Credits™: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Primary Care Network (PCN) and Continuing Education Company, Inc. Primary Care Network is accredited by the ACCME to provide continuing medical education for physicians.

Primary Care Network designates this enduring material for a maximum of 21 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM MOC: Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 21 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Please allow 6-8 weeks for your MOC points to appear on your ABIM records.

AAPA: AAPA accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 21 hours of Category I credit for completing this activity.

AANPCP: The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts AMA PRA Category 1 Credit™ from organizations accredited by the ACCME.

 

Jointly provided by Primary Care Network and Continuing Education Company.

PCN-Logo-new

 

click-here

 

Participant will be leaving Primary Issues and completing this activity on the hosts website.

Click on the link for more detailed information on course content, faculty, etc.

 

 

Published March 21, 2017

 

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When Does Obesity Become a Surgical Problem?

This case study briefly reviews the diagnosis and pre-operative work-up for the surgical management of morbid obesity.

One of your long-term patients schedules a clinic visit with you to discuss her weight. Naomi is a 25-year-old woman who has been struggling with her weight since childhood. Despite repeated attempts at weight loss, including Weight Watchers, the Atkins diet, and most recently a supervised medical fast, she has been unable to lose more than 20 lbs at a time. When she does lose weight, she always regains it within the next six months.

Naomi tells you that her grandmother recently died from complications from obesity-associated diabetes. She is worried that if she does not lose a large amount of her excess weight, she will develop obesity-related complications, as well. In particular, she is worried about diabetes and heart disease. Naomi has a question for you:

“Am I good candidate for gastric bypass surgery?”

You have also been wondering if surgical management is the next step for her and decide to look into the matter further. First you calculate her body mass index (BMI). Naomi is 5 feet 8 inches tall and weighs 270 lbs. In order to calculate her BMI, you can either use an online calculator or convert her height to meters and weight to kilograms. The formula to calculate BMI is

BMI = weight(in kg)/(height (in m))2.

Using this equation, you find that Naomi’s BMI is 41.1, placing her in the obese range for BMI. You explain to Naomi that she meets the BMI requirement for undergoing surgery. If she had a BMI between 35 and 40, she would still be eligible if she had any weight-associated co-morbid conditions. However, she is quite healthy and has no other medical problems.

In addition to meeting BMI requirements, Naomi needs to be screened for psychiatric and physical problems that may interfere with her surgical success. So you ask her, does she have any problems with drugs or alcohol? Does she have any unmanaged psychiatric disorders? Has she had any difficulties getting through surgery in the past? She tells you “no” to all of these questions. Then you turn to the most commonly used guidelines for bariatric surgery developed by the National Institutes of Health (NIH) in 1992.[1]

According to these guidelines, Naomi should have tried medical management of her weight before considering surgical intervention. She tells you that she has attempted programs integrating diet, exercise, and behavior modification without success. She is willing to learn more about bariatric surgery and is motivated to follow through.

What do you do next?

You can recommend that Naomi follow up with a local bariatric surgeon. You should ensure that you refer her to bariatric center that uses an interdisciplinary team approach, one that includes medical, nutritional, psychiatric and surgical expertise. The surgeon should have a good track record and his or her office should be prepared to follow up with Naomi for the rest of her life if she has complications or requires surgical revision in the future.

Watch for next month’s blog on the Medical Management of Obesity. 

[1] Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr. 1992;55(2 Suppl):615S-619S.

 

Dr. V. Silverstein
Durham, NC

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An Influenza-like Illness that is Not Influenza

This case study reviews best practices for diagnosing and treating Lyme disease.

Case study: You are wrapping up clinic in the afternoon, when you see one of your long-time patients in the waiting room.  Bob is a relatively healthy 57-year-old man with a history of well-controlled hypertension. You saw him within the last month and made some adjustments to his medications, but you did not expect to see him back this soon.

When you walk into the examining room, Bob greets you and tells you that he is doing well with his blood pressure. But he has now developed a new-onset fever, headaches, and muscle pain. He is concerned because he feels much worse than he has in the past with these symptoms, and he skipped his flu vaccine this year. What do you do next?

Obviously, the differential diagnosis for these symptoms is vast. Bob could have an infectious disease brought on by a virus, bacteria, or parasite. He could have an underlying malignancy or a drug reaction from his new medication. Your next step is to gather more data by doing a physical exam. On exam, Bob is febrile and slightly tachycardic. His breath sounds are clear; he has no evidence of bruising or bleeding, and no abdominal pain. However, you notice a circular red rash with a central clearing at Bob’s ankle. What do you ask Bob?

You ask Bob if he has had a recent tick bite. A circular red rash with a central clearing is erythema migrans – the pathognomonic sign of Lyme disease. In early stages, the rash may appear like a solid red papule. Given time, the untreated rash will often increase in size and develop a central clearing. Solid red rashes may also be caused by other tick-borne illnesses, so remain vigilant.  You obtain serologies to test for Lyme disease, but given your high index of suspicion for Lyme disease and the fact that you are practicing in a Lyme endemic part of the country, you preemptively treat the patient.

States where Lyme disease is common include Connecticut, Delaware, DC, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, West Virginia, and Wisconsin.[i] People can become infected with Lyme disease in other states if they have traveled to Lyme endemic areas. So remember to ask about travel history and recent tick exposure.

Professional guidelines recommend that providers start high-risk patients on antibiotic treatment even before receiving the final results from laboratory tests. Lyme disease can be prevented by administering a single 200 mg dose of doxycycline within 72 hours of an Ixodes tick bite.[ii] For patients like Bob, a complete course of oral doxycycline is necessary.[iii] Counsel him to take his antibiotics as prescribed and to finish the entire course of treatment in a timely manner.  Recommend that your patients wear long sleeve shirts and pants when they are in forested areas and to check themselves for ticks. Anti-tick sprays can also be effective preventative measures. What if Bob fails to improve or relapses? See what the author would do in the comments section below. Weigh in with your thoughts and join the conversation. 

[i] Centers for Disease Control. Lyme Disease Statistics. Centers for Disease Control Website. https://www.cdc.gov/lyme/stats/tables.html. Updated November 21, 2016. Accessed February 9, 2017.

[ii] Nadelman RB, Nowakowski J, Fish D, et al. Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite. N Engl J Med. 2001;345(2):79-84.

[iii] Wormser GP, Ramanathan R, Nowakowski J, et al. Duration of antibiotic therapy for early Lyme disease. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2003;138(9):697-704.

 

Dr. V. Silverstein
Durham, NC

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Targeting CGRP: Emerging Solutions in Migraine

Targeting CGRP: Emerging Solutions in Migraine

Program Overview1
In light of the evidence regarding the tremendous burden of migraine, leaders in the headache field have called for increased awareness of the availability of preventive efforts.

Dr. Diamond and Dr. Green will engage you in a lively discussion and presentation outlining the current landscape of chronic migraine including future thoughts on acute and preventative treatment. Our experts will share exciting data on new targets under development which have the potential to change the landscape of treatment in the future.

Participate in this interactive and forward-thinking activity to make sure you are prepared and “in the know” on the current and ongoing clinical trials targeting calcitonin gene-related peptide (CGRP) and their impact on the current unmet need in the treatment options for preventive treatment in migraine.

Learning Objectives
After completing this activity, the participant should be better able to:

  • Summarize the current landscape in the management and treatment of chronic migraine
  • Identify emerging therapies targeting CGRP in the treatment of migraine
  • Demonstrate knowledge of the role of the neuropeptide CGRP as a therapeutic target in the treatment of migraine
  • Summarize the current efficacy and safety data of CGRP monoclonal antibodies from clinical trials and their relation to other treatment options for the prevention of migraine headaches

Faculty/Planning Committee

Merle L. Diamond, MD
President, Managing Director
Diamond Headache Clinic
Chicago, Illinois

Mark W. Green, MD, FAAN
Director, Headache and Pain Medicine
Professor of Neurology, Anesthesiology, and Rehabilitation Medicine
Mount Sinai School of Medicine
New York, New York

Release/Expiration Dates
Release Date: December 28, 2016
Expiration Date: December 28, 2017


Accreditation Statement: MediCom Worldwide, Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Designation Statement: MediCom Worldwide, Inc. designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


MediCom Worldwide, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This activity is acceptable for 1.0 contact hour of Continuing Education Credit. Universal Activity Number: 827-0000-16-133-H01-P. Knowledge-based CPE activity.

In order for CPE Monitor to authenticate credit, pharmacists/technicians must provide their e-Profile ID number from NABP and date of birth (in MMDD format) when registering for a CPE program. Please make sure to provide this information in your Member Profile accessed through the login/registration on the home page of this site.


Accreditation Statement: MediCom Worldwide, Inc., 101 Washington Street, Morrisville, PA 19067 is approved by the California Board of Registered Nursing, Provider Number CEP11380. MediCom designates this CNE activity for 1.0 contact hour. Program Number: 16-133-048

Activity provided by MediCom Worldwide, Inc.

Published on Primary Issues, 1/24/2017

Participant will be leaving Primary Issues and completing this activity on the hosts website (Emerging Solutions in Pain).

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‘Tis the Season: Recognizing and Managing Post-Holiday Health Problems

Ah, the winter holidays: warm memories created when loving families get together to celebrate over home-cooked meals and pass down traditions from generation to generation. Or not.

For health care practitioners, January is the time of year when patients come to primary care clinic with season-specific health problems. New-onset chest pain, in particular, seems to be a common concern. At one end of the spectrum are patients who complain of the burning substernal chest pain associated with heartburn from drinking too much alcohol and eating excessively rich foods. On the other end of the spectrum are patients who present, often acutely or too late, with serious cardiovascular events, including myocardial infarctions, acute heart failure, and strokes. In fact, the days between Christmas and the New Year are some of the deadliest all year.

As we learned in medical school, death rates due to cardiac events go up between December 25 and January 7 in what is known as the “Christmas Holiday Effect.”  The commonly held assumption was that temporally, these cardiovascular deaths are associated with cold weather – not excess holiday cheer. However, a new study published last month in the Journal of the American Heart Association suggests that other factors associated with the holidays are more likely to be the cause of cardiovascular deaths than cold temperatures. [1] In this study, the temporal effect of the holidays on cardiovascular health was examined in a part of the world where cold in December is not an issue: the Southern hemisphere. Researchers found that people living in New Zealand were still more likely to die of cardiac events between December 25 and January 7, even though it is summer there. The cause for the temporal uptick in mortality rates does not appear to be related to cold temperature, infectious diseases, or the arbitrariness of the monthly reporting cycle. However, it is unclear what causes the increase in cardiac deaths.  Is it associated with increased alcohol and food consumption, worse emotional stress, delayed care, or displacement of death until after the holidays (where people modify their time of death until after a significant milestone has occurred)? Additional studies are needed.

The holiday season is also associated with other chest-pain inducing health problems, including what is colloquially known as “holiday heart” and panic attacks. Holiday heart syndrome is described as atrial arrhythmias, usually atrial fibrillation, associated with binging on alcohol.[2] However, a new study suggests that alcohol may increase atrial fibrillation at much smaller doses than previously assumed, through a combination of direct toxicity and by contributing to co-morbidities such as hypertension, obesity, and sleep disorders.[3] Any time patients present with arrhythmias or chest pain, it is important for practitioners to ask about alcohol use while obtaining a clinical history. If the EKG shows arrhythmias, practitioners should also remember to check a blood chemistry and normalize any electrolyte disturbances they discover.

Panic attacks also have a temporal pattern, peaking on weekends and holidays.[4] In contrast, the frequency of people evaluated for panic attacks decreases in the middle of the workweek. Potential reasons for increased panic attacks over the holidays may be that patients are more likely to have down-time to perseverate, may be more likely to consume alcohol and illicit drugs, or perhaps the anticipation of work stress is enough to trigger panic attacks in vulnerable patients.

In any case, these new studies serve to confirm what we have long suspected: the post-holiday clinic is different from the clinic at other times of the year. So, as we prepare to answer our patient’s questions about the best way to manage holiday weight gain, quit smoking, and start an exercise program, let’s take the time to consider what other health problems crop up this time of year and prepare to manage them.

Have you experienced the “Christmas Holiday Effect” in your practice?

[1] Knight J, Schilling C, Barnett A, Jackson R, Clarke P. Revisiting the “Christmas Holiday Effect” in the Southern Hemisphere. J Am Heart Assoc. 2016;5(12)

[2] Carey MG, Al-zaiti SS, Kozik TM, Pelter M. Holiday heart syndrome. Am J Crit Care. 2014;23(2):171-2.

[3] Voskoboinik A, Prabhu S, Ling LH, Kalman JM, Kistler PM. Alcohol and Atrial Fibrillation: A Sobering Review. J Am Coll Cardiol. 2016;68(23):2567-2576.

[4] Kao LT, Xirasagar S, Chung KH, Lin HC, Liu SP, Chung SD. Weekly and holiday-related patterns of panic attacks in panic disorder: a population-based study. PLoS ONE. 2014;9(7):e100913.

 

Dr. V. Silverstein
Durham, NC

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