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5 TIWIKLY 5 Things I Wish I Knew Last Year (2015) 5 TIWIKLY 5 Things I Wish I Knew Last Year (2015) Louis Kuritzky, MD University of Florida Family Medicine Residency Program Gainesville, Florida (352)-377-3193 Phone/FAX [email protected] Disclosure Louis Kuritzky, MD has NOTHING TO DISCLOSE In reference to the content of this presentation 1 Objectives • Identify potential therapeutic roles for tranexamic acid • Understand the limitations of AAT replacement therapy • Recognize the weaknesses of current data substantiating triglyceride treatment Disclosure Louis Kuritzky has nothing to disclose in reference to the content of this presentation. 2 5 TIWIKLY 2015 Score Card item # Knew Didn’t Know Keep Toss 1) Lung CA Screen Xray Burden 2) Melanoma Adhesive Patch Dx 3) Thermal Rx & Endothelial Fx 4) False + UDT Methadone 5) TRG Rx to ↓ CVD Risk 6) Warfarin & Dental Surgery 7) What is Tranexamic Acid 8) Menorrhagia & Factor VIII 9) A1AT & Emphysema 10) A1AT Replacement $$ 11) A1AT Efficacy 12) TRG & Pancreatitis How Low Dose is LDCT for Lung Cancer Screening? Arnold is a 62 year old man with a 80 p-y smoking history, who is considering participating in the currently approved protocol for lung cancer screening. He asks you: “It says ‘low dose’ CT. What does that mean?” You would best inform him that a LDCT is equivalent to a) A day in bright sunlight at the beach b)15-20 Chest PA x-rays c) 30-40 Chest PA x-rays d) 110-120 Chest PA x-rays 3 Lung CA Screening: Summary Recommendation “The USPSTF recommends annual screening for Lung CA with LDCT in adults aged 55-80 years who have a 30 p-y smoking Hx and currently smoke or have quit within the past 15 years.” Moyer VA, et al Ann Int Med online accessed 013-Dec-30 “Typical” Effective Doses from X-ray Radiographic Dose Equivalent Study (mSv) #CXR ChestPA 0.013 1 L-spine AP 0.44 30 Mammogram (4 view) 0.2 15 Dental Panorama 0.012 1 BE 5 350 CT L-spine 7 550 CT Abdomen 10 750 CT Chest 10 750 LDCT Chest 1.5 113 Adapted from Linet MS et al CA Cancer J Clin 2012;62:75-100 4 Evolution of Radiation Exposure 1980-2006 2006 per capita dose Other Sources < 0.14 mSv Medical 1980 per capita dose Sources 3.0 mSv Medical Sources Other Sources < 0.05 mSv 0.53 mSv Natural Sources 2.4 mSv Linet MSNatural et al Sources CA Cancer 2.4 mSv J Clin 2012;62:75-100 Linet MS et al CA Cancer J Clin 2012;62:75-100 Evolution of Radiation Exposure (mSv) 1980 2006 Natural Sources 2.4 2.4 Medical Sources 0.53 3.0 CT scans 0.03 1.47 Nuclear Medicine 0.1 0.77 Fluoroscopy 0.4 0.76 Other < 0.05 <0.14 Consumer products --- 0.13 Occupational --- 0.005 Nuclear Power --- 0.0005 TOTALLinet MS et al CA Cancer 3.0 J Clin mSv 2012;62:75-100 5.6 mSv Linet MS et al CA Cancer J Clin 2012;62:75-100 5 Estimated Radiation-Related Cancers from Repeated Screening Age X-ray related Test Frequency (years) CA/100,000 Lung LDCT Q1Y 50-70 230 ( ♂) 850 ( ♀) Coronary Ca++ Q1Y 45-70 40 ( ♂) 55-70 60 ( ♀) Mammography Q1Y <55 45-74 90 Q2Y >55 Linet MS et al CA Cancer J Clin 2012;62:75-100 First Glimpses into the Future From Your Dermatology Time Machine • Differentiation of melanoma from other pigmented skin lesions usually requires a tissue sample. Northwestern University (Chicago) has recently published data on a novel non-invasive methodology. It is ♦ Saliva testing for beta-microglobulin ♦ Adhesive patch testing for mRNA ♦ Ultraviolet light reflectometry ♦ Cutaneous DEXA scanning 6 Melanoma: Some Issues “The incidence of melanoma is ↑ at a rate of 3%-7%/yr for fair-skinned white populations, faster than any other major cancer.” Gerami P et al J Am Acad Dermatol 2014;71:237-44 Melanoma: Some Issues Invasive Depth 10-yr Survival Insitu 100% Breslowdepth < 1 mm >90% Breslowdepth > 4mm <50% Gerami P et al J Am Acad Dermatol 2014;71:237-44 7 Melanoma: Some Issues “While mortality from almost all preventable cancers has markedly decreased since 1975, melanoma-related mortality remains steady….” Gerami P et al J Am Acad Dermatol 2014;71:237-44 Melanoma: Some Issues “A number of studies have shown that early detection through a skin examination allows for Dx at an earlier and more curable state….In 1 study, screening skin examinations reduced mortality by 63%.” Gerami P et al J Am Acad Dermatol 2014;71:237-44 8 A Noninvasive Adhesive Patch Test for Pigmented Lesions • Study: Comparison DermTech adhesive patch vs Bx results (n=150) • Patch MOA: captures mRNA from CMIP & LINC00518 genes • Method: apply & remove patch, then Bx Gerami P et al J Am Acad Dermatol 2014;71:237-44 A Noninvasive Adhesive Patch Test for Pigmented Lesions Patch Bx Classifiction Classification Melanoma Nevus Melanoma 41 6 Nonmelanoma 1 16 Sensitivity 41/42 (97.6%) Specificity 16/22 (72.7%) Gerami P et al J Am Acad Dermatol 2014;71:237-44 9 What About Those False Positives? “Six of 22 cases with a histologic Dx of nevus had a molecular score consistent with a Dx of melanoma. Interestingly, among those 6 cases, 3 had a histologic reading of dysplastic nevus with severe atypia. Unfortunately, it is impossible to determine whether these 3 cases were truly false positives or actually early melanomas.” Gerami P et al J Am Acad Dermatol 2014;71:237-44 10 I Know I Have Risk Factors for CAD, but I HATE to Exercise…. • A 62 year old man with T2DM X 10 years, HTN, and dyslipidemia--all Rx appropriately--gives a ‘2 thumbs down’ to the suggestion of exercise. Which of the following interventions has been shown to improve endothelial function in persons with CAD risk factors? ♦ Magnesium Supplementation ♦ Thermal treatment (sauna) ♦ Ginseng tea ♦ Inversion boots (upside-down suspension) 11 Thermal Rx to Improve Endothelial Function • Study: Japanese men with and without CAD RF (n= 73) • Rx: 15 mins/d dry sauna (60 0 C) X 14 d • Outcome: %FMD (flow-mediated endothelium-dependent dilation) Imamura M, et al J Am Coll Cardiol 2001;38(4):1083-1088 Thermal Rx to Improve Endothelial Fx: Premises Ox-LDL DM HTN Smoking Endothelial Dysfunction Impaired FMD (Flow Mediated Vasodilation) Imamura M, et al J Am Coll Cardiol 2001;38(4):1083-1088 12 Thermal Rx to Improve Endothelial Function * 45% ↑ *emphasis added Imamura M, et al J Am Coll Cardiol 2001;38(4):1083-1088 Thermal Rx to Improve Endothelial Function Baseline PostRx p* p** Control CAD RF CAD RF %FMD 8.2 4.0 <0.0001 5.8 <0.001 %NTG 20.4 18.7 0.32 18.1 NS * vs control **vs preRx Imamura M, et al J Am Coll Cardiol 2001;38(4):1083-1088 13 Thermal Rx & Glucose: Unexpected Payoff? “A significant decrease in FPG concentration [99 mg/dL → 94 mg/dL, p < 0.05] after two weeks of sauna Rx was observed, consistent with the previous report using hot-tub therapy.” Imamura M, et al J Am Coll Cardiol 2001;38(4):1083-1088 An Unexpected UDT + for Methadone • A 56 y.o. house painter fell off a ladder fracturing 3 ribs. He has been prescribed tramadol for pain relief. A UDT comes back positive for methadone. The patient claims he has not taken any methadone. ♦ The pt is lying: FP methadone tests are very rare ♦ His tramadol (Ultram) causes a FP UDT ♦ The quetiapine (Seroquel) he takes for depression is causing a FP UDT for methadone ♦ Endogenous opioids induced by acute pain may cause a FP UDT for methadone 14 False Positive Methadone UDT Case Series of 10 “… 10 inpatients……suffering from mood or psychotic disorders who tested + for methadone. Since such false + methadone screenings may seriously affect the therapeutic relationship, this potential interaction is highly relevant for clinicians. Fischer M et al J Clin Psychiatr 2010;71(12):(LTE)1696-1696 False Positive Methadone UDT Case Series of 10 • All INPATIENTS: methadone access? • All denied methadone use • Gas chromatography-mass spectrometry re-test: methadone negative • All 10 pts Rx with quetiapine (Seroquel) Fischer M et al J Clin Psychiatr 2010;71(12):(LTE)1696-1696 15 False Positive Methadone UDT Case Series of 10 “…this report strongly suggests that positive methadone drug screenings be confirmed by a second method….especially in patients treated with quetiapine.” Fischer M et al J Clin Psychiatr 2010;71(12):(LTE)1696-1696 The Triglyceride Story: CVD Risk Reduction • Your new pt Jason W is an obese (BMI 32) 36 y.o. construction worker who requests a fibrate refill for Rx of ↑TRG (off-Rx = 380, on-Rx = 110). He denies pancreatitis. He drinks ‘a couple beers’ after work every day. He has no personal/FH of CVD, but was told by his since-retired GI Doc to take the fibrate to reduce his risk of CVD, which he has done for the last 3 years. He does not have HTN or T2DM. The fibrate causes no AEs. a) Refill the Rx as-is: success is success b) Increase the fibrate dose: his TRGs could be improved c) Decrease the fibrate dose: TRG ≤150 would be OK d) Decline to fill the Rx due to lack of outcomes evidence 16 Two Basic Clinical Questions • Has pharmacologic Rx of elevated triglycerides been PROVEN to improve CV outcomes? • Has pharmacologic Rx of triglycerides been PROVEN to reduce risk for pancreatitis? Two Basic Clinical Answers • ↓ CVD?: No RCT has demonstrated this 17 The Triglyceride Story: UpToDate 2014 CVD Risk Reduction with Rx: Uncertain “It is uncertain whether pharmacologic therapy targeted at reducing TRG levels will reduce CV risk.” Rosenson RS “Approach to the patient with hypertriglyceridemia” UpToDate accessed 9/2414 The Triglyceride Story: UpToDate 2014 Preventing Pancreatitis: No High Quality Evidence “Although high quality evidence is lacking, for primary prevention of pancreatitis, we and others suggest initiating pharmacologic therapy to reduce TRG when fasting concentration is >1000 mg/dL” Rosenson RS “Approach to the patient with hypertriglyceridemia”
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