Inflammatory Bowel Diseases (IBD) What The Primary Care Physician Needs to Know Practical Updates for Primary Care
11/7/2014 Practical Updates for Primary Care Mansfield, TX Inflammatory Bowel Diseases (IBD) What The Primary Care Physician Needs to Know Themos Dassopoulos, M.D. Director, Center for IBD Baylor University Medical Center [email protected] Unlabeled uses of drugs in IBD Sulfasalazine (CD), Mesalamine (CD) Ciprofloxacin , Metronidazole 6‐mercaptopurine, Azathioprine, Methotrexate Cyclosporine 1 11/7/2014 Inflammatory Bowel Diseases (IBD) • Complex diseases – UC is not one disease – CD is not one disease – Each patient is unique • Chronic disease management – Educate and empower patients – Collaboration between primary provider, gastroenterologist and other providers Types of IBD • Ulcerative Colitis • Crohn’s disease • Indeterminate colitis • Microscopic colitis • Pouchitis • Diverticular‐disease associated colitis 2 11/7/2014 Overview • • • • Pathogenesis Manifestations Management Role of primary care physician Pathogenesis of IBD 3 11/7/2014 NOD2/CARD15 • 25–35% of Caucasians with CD have 1‐2 NOD2 mutations • Two mutations • One mutation → x 20‐40 risk → x 2‐4 risk • Youthful onset • Ileal disease (rather than colon‐only) • Fibrostenotic behavior NOD2/CARD15 • Expressed in macrophages, dendritic and ileal Paneth cells • Cytosolic receptor for bacterial cell wall peptidoglycan • Activates NF‐κB • CD: Loss of function mutation • Decreased defense to gut bacteria 4 11/7/2014 Genetics have uncovered two major CD pathways Innate Immunity Defective Handling Of Bacteria NOD2 ATG16L1 IRGM Th17 Pathway/ IL23 IL23R IL12B TYK2 JAK2 STAT3 Unifying hypothesis • Primary dysregulation of the mucosal immune system, leading to excessive immunologic responses to normal microflora • Changes in the composition of gut microflora and/or deranged epithelial barrier function may facilitate the abnormal immune response Strober, JCI 2007 5 11/7/2014 Pathogenesis Abnormal gut flora • Diet Environment Modifiers: • Smoking • NSAIDs Mucosal Inflammation Genetics • Defective handling of bacteria • Mucosal immune responses • Barrier function of epithelium Manifestations 6 11/7/2014 Heterogeneity of Disease Location Ulcerative Colitis • Proctitis • Proctosigmoiditis Symptoms of distal disease • Left‐sided disease • Extensive • Pancolitis Systemic symptoms Extraintestinal 7 11/7/2014 Ulcerative Colitis • • • • Bloody diarrhea Urgency Tenesmus Inability to discriminate flatus from BMs • Constant abdominal and fever are uncommon symptoms in uncomplicated UC Endoscopic score 8 11/7/2014 Variable phenotypes ‐ Crohn’s Diseases • Location – Ileal – Colonic – Ileocolonic − Upper GI − Jejunal − Perianal • Transmural aggressiveness – Inflammatory – Stricturing (fibrostenotic) – Penterating (fistulizing) CD Phenotypes Inflammation Pain Tenderness Diarrhea Penetrating Enteroenteric Enterovesicular Retroperitoneal Enterocutaneous Abscesses Stricturing Pain Distension Vomiting Sitophobia Borborhygmi 9 11/7/2014 Phenotype is dynamic • Proctitis may evolve into pancolitis • Inflammatory CD may evolve into stricturing and/or penetrating disease Perianal fistulae Schwartz DA Ann Intern Med 2001 10 11/7/2014 Watering Can Perineum Courtesy of J. Fleshman MD Classic Extra‐intestinal Manifestations (EIMs) Joint • Peripheral arthritis • Sacroiliitis • Ankylosing spondylitis (SpA) Skin • Erythema Nodosum (EN) • Pyoderma Gangrenosum (PG) Liver • Primary Sclerosing Cholangitis (PSC) Eye • Episcleritis • Iritis 11 11/7/2014 Relation of EIMs to colitis • Usually in patients with UC or Crohn's colitis • Peripheral arthritis, EN, and episcleritis are related to the activity of the colitis –More common in extensive colitis and pancolitis • Ankylosing spondylitis, sacroiliitis, and PSC are independent of disease activity • PG and iritis may or may not be related to disease activity Orchard, Gut 1998 12 11/7/2014 Spondyloarthropathy • • • • Ankylosing Spondylitis Sacroiliitis (symmetrical) Peripheral arthropathy Enthesitis: – Achilles’ tendinitis – Plantar fasciitis – Dactylitis Other • Colorectal cancer (UC and CD of the colon) • Hypercoagulable state • Malabsorption (CD of the small bowel) – Vitamin B12 – Vitamin D • Anemia (multifactorial) • Steroid‐dependence • Metabolic bone disease 13 11/7/2014 Management Goals of Therapy • • • • • • • Induction of remission Maintenance of remission Improved quality of life Prevention of complications Restoring and maintaining nutrition Optimization of surgical intervention Mucosal healing 14 11/7/2014 Management principles • Induction of clinical remission maintenance of clinical remission • Choice of therapy depends on disease severity and disease location • Targeted therapy (Mesalamine, Steroids) • Compliance Classes of IBD therapies Aminosalicylates • Sulfasalazine • Mesalamine (5ASA) Asacol, Pentasa, Colazal, Lialda, Apriso • 5ASA enemas and suppositories Antibiotics* Ciprofloxacin (CD), Metronidazole (CD) Corticosteroids • Prednisone, • Budesonide (ileocolic, colonic release) • Topical (hydrocortisone enemas and suppositories) • IV (methyprednisolone,hydrocortisone) *Antibiotics are used for colonic Crohn’s and to prevent post‐operative recurrence 15 11/7/2014 Classes of IBD therapies Immunomodulators 6‐mercaptopurine (CD, UC) Azathioprine (CD,UC) (IMM) Methotrexate (CD) Cyclosporine (UC) Anti‐TNF Infliximab (CD,UC) Adalimumab (CD,UC) Certolizumab (CD) Golimumab (UC) Anti‐4 integrin Natalizumab (CD) Vedolizumab (UC, CD) Treatment toxicities • Mesalamine – Renal dysfunction, diarrhea • Ciprofloxacin – C. difficile infection, tendonitis and tendon rupture • Metronidazole – Peripheral neuropathy • Steroids: Too many to list 16 11/7/2014 Thiopurine toxicities Common Uncommon and rare Leukopenia (10‐20%) Non‐melanoma skin cancer Transaminitis (10‐20%) Bacterial infections (with neutropenia) Pancreatitis (3%) Reactivation of HBV Herpes zoster Lymphoma CMV colitis Nodular regenerative hyperplasia Methotrexate toxicities Nausea, emesis, fatigue (give folic acid) Stomatitis Leukopenia Liver fibrosis and cirrhosis Interstitial pneumonitis and pulmonary fibrosis Infections are rare No reports of lymphoma 17 11/7/2014 Anti‐TNF toxicities Infusion reactions Infections TB, Herpes zoster, Reactivation of HBV, Endemic mycoses: Histo, coccidioidomycosis, blastomycosis Opportunistic: aspergillosis, cryptococcosis, pneumocystis Cutaneous reactions Hepatotoxicity Demyelinating disease Vasculitis Heart failure Melanoma Cytopenia No proof of increased incidence of lymphoma Anti‐TNFTherapy • Similar efficacy – No head‐to‐head trials – Induction: ≈ 60% response – Maintenance: ≈ 40% response • Similar safety • Anti‐drug antibodies (ADA) (10‐15%/year) Loss of response • Immumodulators decrease ADA 18 11/7/2014 Considerations in selecting anti‐TNF • Efficacy • Safety • Immunogenicity Cost Convenience Compliance Therapy of Ulcerative Colitis Severity Induction Maintenance Mild Oral 5‐ASA, and/or Topical 5‐ASA, and/or Topical steroids Moderate Oral steroids Mesalamine Steroid‐dependent AZA or 6MP Anti‐TNF (±AZA/MP) Severe Oral 5‐ASA, and/or Topical 5‐ASA Anti‐TNF (±AZA/MP) Intravenous steroids AZA or 6MP Intravenous cyclosporine AZA or 6MP Anti‐TNF (±AZA/MP) Anti‐TNF (±AZA/MP) 19 11/7/2014 Therapy of Inflammatory CD Severity Mild Induction Oral 5‐ASA, and/or Antibiotics, and/or Budesonide Moderate Budesonide, Prednisone Severe Maintenance Oral 5‐ASA, and/or Antibiotics AZA, 6MP, or MTX Anti‐TNF (±AZA/MP/MTX) Anti‐TNF (±IMM) Intravenous steroids AZA, 6MP or MTX Anti‐TNF (±AZA/MP/MTX) Anti‐TNF (±IMM) Anti‐4 Anti‐4 20 11/7/2014 Managing the risk of infection • • • • • Vaccinations (Flu, pneumovax, HPV, HAV, HBV) Screen for TB and HBV Warn patient about risk, avoidance to exposure Vigilance Fever? Rigors? Night sweats? Malaise? – Patients should carry a thermometer – call if T>100.5‐101 • Think about unusual infections • Always err on the side of caution 21 11/7/2014 Causes of Intestinal Obstruction in CD • Stricture plus dietary indiscretion • Acute active inflammation superimposed on a stenotic bowel segment • Adjacent phlegmon or abscess with mass effect • Intra‐abdominal adhesions Management of Obstruction • NPO, nasogastric aspiration, correct fluid and electrolyte disturbances, and avoid narcotics • Consult an experienced surgeon • Steroids or infliximab if symptoms and signs of systemic inflammation (fever, night sweats, arthralgias, elevated ESR and CRP) 22 11/7/2014 Management of Obstruction • Repeated episodes of SBO due to fibrostenotic CD are treated with surgery • Strictured ileocolic anastomoses can be dilated endoscopically Abscesses in CD • Drainage (percutaneous) • Treatment with antibiotics • Supportive therapies: NPO, TPN, IVF and electrolytes • No corticosteroids • Infliximab vs. surgery 23 11/7/2014 Perianal CD • • • • • Tags, fissures, abscesses, fistulae, strcitures 20‐40% incidence Association with rectal and colonic disease Drainage, fluctuance, tenderness, induration, DDx: Ca (squamous, adeno, lymphoma), hidradenitis suppurativa, infxn (TB, HIV, HSV), Seton • Continually drains fistula • Prevents abscess formation • Reduces peri‐fistula inflammation • Can be left in place indefinitely Abscess Seton 24 11/7/2014 Soft Seton Courtesy of James Fleshman MD Common mistakes in UC • • • • • • • Not using topical therapies Routinely prescribing antibiotics Routinely obtaining a CT scan Not feeding the patient Not consulting surgery Not knowing when to call it quits Prematurely converting IV to oral steroids 25 11/7/2014 Common mistakes in CD • Missing stricturing or penetrating CD • Rx stricturing or penetrating CD with steroids • Perianal disease: – Treating with steroids – Delaying drainage of abscess • Delaying surgery for stricturing disease • No plan to prevent post‐op recurrence • Excessive use of CT Surgery for UC • Curative • Proctocolectomy with – end ileostomy – ileal pouch anal anastomosis (IPAA) 26 11/7/2014 Surgery for CD • Not curative • High risk of recurrence • Intestinal obstruction – Resection – Stricturoplasty • Fistulae and abscesses – Resection Role of primary care physician 27 11/7/2014 Role of primary care physician • Care coordination • Reinforcing the message –Balancing benefits and risks –Encouraging compliance –Infection risk Communicating benefits and risks • • • • • IMM and biologics dramatically improve QOL There are serious, but very rare side effects Benefits generally outweigh the risks Understand the trade‐offs Individualize decision 28 11/7/2014 Role of primary care physician • Monitoring – Disease activity – QOL • Smoking cessation • Bone health IBD Health Maintenance Checklist Therapy and Monitoring Vaccinations Bone Health CA screening IBD type, location Flu shot* 25OH‐vitD Colon CA IBD activity Pneumovax DXA Steroid‐sparing RX Tdap HPV Ca++‐vitD Meningococcus Smoking cessation HAV HBV Skin CA (IS, anti‐TNF) Cervical CA (IS, anti‐TNF) IS, immunosuppressants Renal (5ASA) TPMT enzyme (AZA/6MP) CBC/CMP (IS) HBV screen (AZA, aTNF) TB screen (anti‐TNF)* JCV Ab (natalizumab)** MMR Varicella Zoster [if no immunity & NO plans for IS in next 4‐12 wks] * Annually **Every 6 months Again @ 5 yr and @ 65 When risk factors are present 29 Hematological malignancies –few basics of diagnosis Binu Nair, MD, FACP Hematology Oncology. Baylor Scott & White Health. Waxahachie. 1 • Goals of the talk • Discuss few key points to remember when working up common hematological malignancies. • Lymphoma/ lymphadenopathy • Multiple myeloma. • Leukemia/MDS/MPN‐ not included 2 • There are no standard screening guidelines for hematological malignancies. • Usually patient presents to ER or PCP’s office 3 • 20 year old women with no past medical history presents with neck lymphadenopathy palpable 2x2 cm, cough for 6 months ,basic evaluation included CT of chest shows large right mediastinal mass about 10 cm. • Excisional bx if palpable and accessible, because high likely Lymphoma based on the imaging and age. 4 • 66 year old obese women with left axilla Lymphadenopathy, • CBC normal and rest exam normal, ROS normal. • Work up for breast cancer. 5 • 67 year old man who is a heavy smoker, now with mediastinal, neck and axilla Lymphadenopathy, and peripheral blood shows total WBC of 15,000. differential include 90% lymphocytes. • Peripheral blood for flow cytometry, likely CLL, no biopsy indicated usually (there are exceptions) 6 • Lymphadenopathy, an abnormality in the size or character of lymph nodes, is caused by the invasion or propagation of either inflammatory cells or neoplastic cells * • It results from a vast array of disease processes, can be very non specific. • Work up always individualized. • Malignancy is rare. *Am Fam Physician. 2002 Dec 7 • Localized lymphadenopathy can be observed for 2‐4 weeks • provided history and physical examination suggest no malignancy • Tx if infections, if indicated. • Biopsy if not resolved in 2‐3 weeks • immediately if suggesting malignancy. • Multidisciplinary approach • • • • • • • PCP Oncologist Surgeons Radiologist Specialist.. Pathologist general‐>>Hemato pathologist Molecular pathologist. 8 • Lymphomas • are malignant tumors of lymphoid tissues with either B or T cells. • Can be curable, depending on the types, even in advanced case with poor performance status. 9 B Cells NHL T Cells Lymphoma HL NK cells 10 5 11/7/2014 • Etiologies ‐Unknown mostly • Genetic, environmental • Autoimmune • Lupus/Sjogrens/RA • Celiac sprue • Infectious agents • HIV , EBV • Hepatitis C • H Pylori • Poor immune system • Some are Indolent • grows slowly and produces few/no symptoms • examples • Follicular lymphoma (grade I and II) • Marginal zone B‐cell lymphoma • may not need treatment always 12 • But some are aggressive or very aggressive… • grows quickly and causes serious symptoms • Diffuse large B‐cell lymphoma • Burkitt's lymphoma • Always need treatment • Urgent work up, urgent treatment. • Time is very important ! 13 14 Low grade vs high grade on PET.CT 15 • General manifestations. • Depending on the affected area, nodes, organs‐ mass effect • Lymphocytosis‐ Leukemic phase • B symptoms‐ wt loss, fever, night sweats, fatigue • Skin rash ‐many types. • Paraneoplastic • Leukocytosis, thrombocytosis, anemia, eosinophilia, high total protein • Indolent lymphomas can be asymptomatic for months to years 16 Mediastinal mass, young patients. • 4 T. ‐Thymomas ‐Thyroid ‐Teratoma ‐"Terrible" lymphoma • Hodgkin's lymphoma • More common • Non Hodgkin's • Less common • Acute lymphoblast Lymphoma/Leukemia. • Primary mediastinal Lymphoma. • Sarcoidosis. 17 Lymphoma on the skin Present as simple to severe rash, itching, might need repeat biopsy , review by dermato pathology-experts 18 • Initial evaluation • Clinical exam, History • Localized, Generalized, associated symptoms. • Review medications‐ • Phenytoin, allopurinol, hydralazine, etc. • Infections‐ acute chronic? • HIV, TB, Syphilis, EBV etc, • Inflammations acute = chronic • Sarcoidosis, lupus, other autoimmune disease • CBC, CMP, HIV. • Imaging CT‐PET/CT. 19 • Large tissue sample. • avoid Fine Needle Aspiration when ever possible • • • • acurate Dx, subtypes, molecular evaluations. Some represent lower ‐higher grade within a single node 1‐10% of node is malignant ! In Hodgkin's lymphoma. Can have granuloma, atypical, reactive finding as a part of malignancy and infections and inflammations. 20 10 11/7/2014 • Excisional biopsy‐ depending on the location • general surgeons/surgical oncologist/ENT/Urologist/ etc • Core Bx • FNA • Mediastinoscopy • Bone marrow bx ‐usually use for staging. • Colonoscopy/EGD • Bronchoscopy‐usually small samples not preferred if suspect lymphoma, unless no other easy choice. 21 • Which node to biopsy ? • Depends on the clinical situation. • Some times most palpable and easily accessible. • But some times most avid of the PET/CT • Areas less preferred to biopsy • • • • if radiology thinks reactive Inguinal. areas near inflammations. less intense on the PET/CT 22 • 69 year old man ,chronic smoker , with left side upper neck node palpable, hard, non tender 2x2 cm, for 1 month, growing slowly, voice has been different and loosing weight. • What type of biopsy first • FNA ? • Excisional ? • Core ? 23 • Head neck region. • In general avoid open biopsies, unless neck dissection as primary treatment is planned by experienced surgeons • It adversely affect the success of subsequent surgical resection • Prefer ENT to biopsy this if suspect head and neck or cancer of unknown primary and only on the neck • Unless lymphoma was very likely 24 • How we made diagnose. • Histology. • Immunohistochemistry. • Flowcytometry. • can be peripheral blood if suspicious cells. • mass/fluids. • • • • Molecular. Cytogenetic. Imaging studies. Clinical information. 25 Non Hodgkin lymphoma. Hodgkin's lymphoma. 26 Sweet syndrome/acute neutrophilic dermatosis Sudden onset of fever, skin lesions, bx will show neutrophils infiltrates reactive process in response to systemic factors, such as hematologic disease, infection, inflammation, vaccination, or drug exposure. 27 • Multiple myeloma (MM) – • proliferation of a single clone of plasma cells ‐ • make abnormal immunoglobulins. • Major delay in diagnosis has negative impact on the disease course 28 29 30 • 60 year old Caucasian man sees his PCP for routine check up Physical exam unremarkable, ROS are unremarkable except mild back pain. • Basic labs shows • • • • • Hb Calcium Cr Albumin total protein 12.9 10.4 1.2 3.0 10.0 • 9 months after patient admitted to hospital with compression fracture to T4 and severe pain with disabilities • Dx Multiple myeloma. 31 • Suspect Multiple Myeloma if • • • • • • • • • • High total serum protein , low albumin. Unexplained anemia, back/bone pain, Osteolytic lesions, osteopenia/osteoporosis and/or pathologic fractures unexplained Hypercalcemia Renal failure Recurrent infections, hypogammaglobulinemia. Nephrotic syndrome due to concurrent primary amyloidosis. Neuropathy unexplained Low anion gap Weight loss, anorexia, fatigue 32 33 Am Fam Physician. 2008 • protein electrophoresis (SPEP) separates proteins • for the detection and quantification of an M‐protein‐ urine/blood 34 • Immunofixation confirms the presence of an M‐protein and determines its type • differentiate a monoclonal from a polyclonal increase in immunoglobulins Monoclonal IgG, Kappa. 35 • The serum free light chain (FLC) assay • detect free light chains (ie, kappa or lambda) in the serum. • more sensitive for the detection of light chains than urine immunofixation. • may be affected by the presence of renal failure, chronic or acute inflammations. 36 • Screening at Office. • CBC, calcium, albumin, total protein • SPEP+ immunofixation+ UPEP+ immunofixation – 97% OR. • SPEP+ immunofixation + free light chains ratio. • Depending on the results • Bone survey – lytic lesion most of the time, some times mixed. • + /‐ Dexa scan, MRI • Bone marrow biopsy. 37 2‐3% non secretory Am Fam Physician. 2008 38 • Polyclonal gammopathy vs monoclonal • Both have increase total protein, not always. • Monoclonal gammopathies • a clonal process that is malignant or potentially malignant. • MGUS, Myeloma, Lymphoma, Lymphoid/Leukemias, amyloidosis,MGUS. • Polyclonal gammopathies • reactive or inflammatory process, • usually are associated with nonmalignant conditions, Normal Monoclonal Polyclonal 39 Polyclonal gammopathies Increased total proteins • • • • • • Liver disease – 61 & Connective tissue disease – 22 % Chronic infection – 6 % Hematologic disorders – 5 % ! Non‐hematologic malignancy – 3 % Other – 3 % Am Fam Physician. 2005 Jan , Mayo Clin Proc. 2001;76(5):476 40 • Anemia of chronic disease • Always careful, unless there is an explanation. • Chronic disease of what ? • Almost all advanced hematological malignancies and other solid malignancies associated with anemia. 41 • 66 year old man found to have 2 cm lung mass during routine check up for bronchitis. Had bronchoscopy and biopsy came back negative patient did not follow up since he was told no cancer !. • 3 years later presenting with seizure and found to have lung cancer metastasis to brain. • curable ‐>incurable… 42 • 44 year old man presented with left axillary and neck lymphadenopathy for 3 months. • Had core biopsy both side since patient did not want to go through surgery and both came back reactive/granuloma ! • Patient was discharged from surgery clinic. • Pt does not have follow up. • Patient visits ER with cord compression 5 months after. • Dx Hodgkin's lymphoma. 43 • Biopsy negative ! No cancer?? • reactive, atypical, granuloma, no organ tissue etc • FNA negative? • need careful assessment‐ unless specific reason or mass resolved. 44 Binu Nair, MD, FACP Hematology Oncology. Baylor Scott & White Health. Waxahachie [email protected] 318 840 4841. 45 11/7/2014 Clinical Updates Physical Medicine and Rehabilitation Brite John Chalunkal November 1, 2014 Disclosure • None 1 11/7/2014 Outline • • • • • • What is PM&R Imaging for back pain Interventional Pain Procedures EMG Wheelchair Clinic Cancer Rehabilitation Basics • Physical Medicine and Rehabilitation – PM&R • related terminology – physiatry / physiatrist (fiz•zee•AT•trist) – rehabilitation medicine – interventional physiatry 2 11/7/2014 What is PM&R? "Branch of medicine emphasizing prevention, diagnosis, and treatment of disorders – particularly related to nerves, muscles, and bones – that may produce temporary or permanent impairment." ‐ American Academy of PM&R In Other Words… "Rehabilitation physicians are nerve, muscle, and bone experts who treat injuries or illnesses that affect how you move." ‐ American Academy of PM&R 3 11/7/2014 Another Laymen’s Definition "A branch of medicine which aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities." ‐ Wikipedia.org Quick Clarification • Impairment – anatomical or physiological dysfunction • Disability – unable to perform a human activity • Handicap – unable to meet a societal role 4 11/7/2014 A Very Brief History origin: as early as heat/cold modalities used for health benefits defined: principles formulated during post‐WWI consolidated & expanded: post‐WWII established: approved as med specialty in 1947 Common Conditions 5 11/7/2014 Evaluation physical exam and imaging Evaluation electromyography nerve conduction study 6 11/7/2014 Problem List • • • • • • Neurogenic Bladder Malnutrition Dysphagia Ventilation Constipation Pain • • • • • • • • • • Skin Breakdown Heterotopic Ossification Gait Dysfunction Seizures Depression Insomnia Deep Vein Thrombosis Radiculopathy Spasticity and Contracture Permanent Impairment Some Solutions Problem List • • • • • • Neurogenic Bladder Malnutrition Dysphagia Ventilation Constipation Pain • Skin Breakdown • Heterotopic Ossification • Gait Dysfunction • Seizures Orthoses • Depression • Insomnia • Deep Vein Thrombosis • Radiculopathy • Spasticity and Contracture • Permanent Impairment 7 11/7/2014 Some Solutions • • • • • • Neurogenic Bladder Malnutrition Dysphagia Ventilation Constipation Pain • Skin Breakdown • Heterotopic Ossification electrical • Gait Dysfunction stimulation • Seizures • Depression • Insomnia • Deep Vein Thrombosis • Radiculopathy thickening • Spasticity and Contracture mix • Permanent Impairment Some Solutions • • • • • • Neurogenic Bladder Malnutrition Dysphagia Ventilation Constipation Pain • Skin Breakdown • Heterotopic Ossification • Gait Dysfunction • Seizures Gait Training • Depression • Insomnia • Deep Vein Thrombosis • Radiculopathy • Spasticity and Contracture • Permanent Impairment 8 11/7/2014 Some Solutions • • • • • • Neurogenic Bladder • Skin Breakdown baclofen Malnutrition • Heterotopic Ossification botox pump Dysphagia • Gait Dysfunction Ventilation • Seizures Constipation • Depression manual Pain • Insomnia therapy • Deep Vein Thrombosis • Radiculopathy • Spasticity and Contracture • Permanent Impairment Some Solutions • • • • • • Neurogenic Bladder Malnutrition Dysphagia Ventilation Constipation Pain • Skin Breakdown • Heterotopic Ossification heat/cold • Gait Dysfunction • Seizures water • Depression • Insomnia therapy • Deep Vein Thrombosis • Radiculopathy transcutaneous • Spasticity and Contracture electrical nerve • Permanent Impairment stimulation 9 11/7/2014 Some Solutions • • • • • • Neurogenic Bladder Malnutrition Dysphagia Ventilation Constipation Pain • Skin Breakdown • Heterotopic Ossification • Gait Dysfunction • Seizures • Depression • Insomnia • Deep Vein Thrombosis prostheses • Radiculopathy • Spasticity and Contracture • Permanent Impairment Task at Hand 1. 2. 3. 4. Optimize Function Pain Relief Prevent & Manage Complications Coordinate Care above all, 5. Educate Patients 10 11/7/2014 Day in the Life of a Physiatrist… Practice Settings Inpatient Hospital Unit Free‐Standing Rehab Acute Rehab Nursing Home Outpatient Hospital Clinic Free-Standing Rehab Acute Rehab Private Office 11 11/7/2014 Sample Inpatient Experience Spinal cord Traumatic Brain Stroke Polytrauma Pediatric • • • • • Burn Cancer Transplant Orthopedic Pulmonary Chronic Neurology Disorder (e.g., MS) • Complex Medical Disorders • • • • • • Sample Outpatient Experience • • • • • Amputee Wound Care Spasticity Musculoskeletal Stroke • • • • • • • • • EMG & NCS Pain Ortho‐Rehab Spine General Pediatric Arthritis Fibromyalgia Spina Bifida 12 11/7/2014 Interdisciplinary Team Medical Professionals • • • • Critical Care Intensive Medicine General Surgery Neurology • • • • Neurosurgery Orthopedics Psychiatry Urology Interdisciplinary Team (cont’d) Allied Health Professionals • • • • Dietetic Rehabilitation Nurse Occupational Therapy Recreational Therapy Physical Therapy Prosthetics & Orthotics Psychology Respiratory Therapy Social Worker Speech & Language Therapy • Vocational Counseling • • • • • • 13 11/7/2014 PM&R Residency Option A Option B Categorical Preliminary Option C Transitional PGY-1 PGY-2 PGY-3 PGY-4 Fellowship Fellowships Electrodiagnostic Medicine Hospice and Palliative Medicine* Interventional Spine Neuromuscular Medicine* Pain Medicine* 14 11/7/2014 Fellowships (cont’d) Pediatric Rehabilitation* Spinal Cord Injury* Sports Medicine* Traumatic Brain Injury Stroke etc… * denotes sub-specializations formally recognized by AAPMR Back Pain ‐ When to order imaging • • • • • Choosing Wisely American Academy of Family Physicians American College of Physicians North American Spine Society American College of Radiology 15 11/7/2014 • Approximately one‐quarter of patients 18 to 50 years of age with acute low back pain who received imaging tests had no identifiable indication for imaging Facts on Normal Patients ●In one study, 23 percent of asymptomatic adults had degenerative changes on plain x‐rays of the lumbar spine ●In a community‐based study of 188 individuals 40 to 80 years old, 60 percent of males and 67 percent of females had facet joint osteoarthritic changes on lumbar CT scans ●Disc herniations on MRI are seen in 22 to 36 percent of asymptomatic adults, and spinal stenosis is present in up to 21 percent of studies in patients over age 60 16 11/7/2014 MRI‐ Relevant vs Common Finding • One study reported that moderate or severe central stenosis, root compression, and disc extrusions were likely to be diagnostically relevant . • Other MRI findings, however, were common in people without back pain (desiccation of discs, bulging discs, disc protrusion, loss of disc height). Spondylolysis • Spondylolysis (a defect in the pars interarticularis of the neural arch, usually due to a stress fracture) seen on radiograph is equally common in patients with and without low back pain symptoms 17 11/7/2014 Imaging prior to trial of therapy Presentation ‐ Onset Acute Low Back Pain Acute Low Back Pain Imaging Type Radiography MRI Risk Factors / Findings major for cancer spinal infection , cauda equina syndrome or severe or progressive neurologic deficits. After trial of therapy (PT) Presentation ‐ Onset Acute Low Back Pain Acute Low Back Pain Imaging Type Radiography MRI Low risk of cancer( wt loss ) , risk factors for AS, risk factors for compression fractures signs/symptoms of radiculopathy or stenosis and candidates for epidural injection or surgery Risk Factors / Findings 18 11/7/2014 • Repeated imaging only recommended with new or different low back pain • MRI without contrast is generally considered the best initial test for most patients with low back pain who require advanced imaging • MRI enhancement with IV gadolinium allows the distinction of scar from disc in patients with prior back surgery Harms of unnecessary imaging Radiation exposure (for lumbar radiography and CT) Labeling Hypersensitivity reactions and contrast nephropathy (for iodinated contrast with CT) Potential association with subsequent unnecessary, invasive, and expensive procedures 19 11/7/2014 Harms of unnecessary imaging Radiation exposure (for lumbar radiography and CT) Labeling Hypersensitivity reactions and contrast nephropathy (for iodinated contrast with CT) Potential association with subsequent unnecessary, invasive, and expensive procedures Talking to patients regarding Imaging • Risk factor assessment can almost always identify patients who require imaging • The prevalence of serious underlying conditions is low in patients without risk factors • The natural history of acute low back pain is quite favorable, but patients require reevaluation if they are not better after about 1 month 20 11/7/2014 • Routine imaging does not improve clinical outcomes but increases costs and may lead to potentially unnecessary invasive treatments, such as surgery • Imaging abnormalities are extremely common, especially in older adults, but most are poorly correlated with symptoms In most cases, treatment plans do not change after imaging studies • Back imaging is associated with radiation exposure, which can increase the risk for cancer in the case of lumbar radiography and computed tomography Interventional Procedures • Epidural Injection Lumbar/ Cervical • Facet Injections • SI Joint injections • Medial Branch Blocks/ Ablations • Sympathetic Blocks 21 11/7/2014 Epidural Steroid Injections • “Epidural” describes an anatomic space • Can be accessed via injection from different routs – Interlaminar – Transforaminal – Caudal 22 11/7/2014 Summary of the Evidence • Supports the use of both interlaminar and transforaminal corticosteroid injections for radicular pain as a result of spinal stenosis or disk pathology for short‐term analgesia • Modest benefits for variable periods of 2 weeks to perhaps 3 months Cervical Interlaminar ESI • Most safely performed at the C7‐T1 level • Epidural space is widest here • Interlaminar openings is viewed in maximum diameter, usually with a caudocephalad angulation of the intensifier 23 11/7/2014 Cervical Interlaminar ESI • Interlaminar openings is viewed in maximum diameter, usually with a caudocephalad angulation of the intensifier • Lamina immediately inferior to the interlaminar opening target is marked Cervical Interlaminar Epidural 24 11/7/2014 Cervical Interlaminar Epidural Cervical Interlaminar Epidural 25 11/7/2014 Cervical Interlaminar Epidural Cervical Interlaminar Epidural 26 11/7/2014 Cervical Interlaminar Epidural Transforaminal Lumbar ESI • Pt. prone • Oblique view with SAP at desired level • Target at 6 o’clock position of pedicle at same level • Needle advanced with incremental fluoroscopic images until tip approaches appropriate depth • AP and lateral images obtained 27 11/7/2014 Transforaminal Lumbar ESI • Needle tip should be in “safe triangle” or dorsal to the dorsal root ganglion • Nonionic contrast injection demonstrates neurogram as well as epidural spread 28 11/7/2014 29 11/7/2014 30 11/7/2014 31 11/7/2014 Complications • • • • • • Related to technique used Related to needle trauma Vasospastic or ischemic changes Infection Drug related complications Drug additives Epidural Steroids Interlaminar • Complications • Dural Puncture • Headache • Exacerbation pain • Hypotension 1‐5% 1‐2% 1% 2% • Therefore, even a relatively basic procedure • has a significant rate of morbidity 32 11/7/2014 EMG – indications • EMG and nerve conduction studies are an extension of the physical examination. • They can be useful in aiding in the diagnosis of peripheral nerve and muscle problems. This can include peripheral neuropathies, entrapment neuropathies, radiculopathies, and muscle disorders. New Pain Medications • Movantik (naloxegol); AstraZeneca; For the treatment of opioid‐induced constipation in adults with chronic non‐cancer pain, Approved September 2014 • Targiniq ER (oxycodone hydrochloride + naloxone hydrochloride) extended‐release tablets; Purdue Pharma; For the management of severe chronic pain, Approved July 2014 • Tivorbex (indomethacin); Iroko Pharmaceuticals; For the treatment of acute pain, Approved February of 2014 33 11/7/2014 New Pain Medications • Xartemis XR (oxycodone hydrochloride and acetaminophen) extended release; Mallinckrodt Pharmaceuticals; For the management of acute pain, Approved March 2014 • Zohydro ER (hydrocodone bitartrate) Extended‐Release Capsules; Zogenix; For the management of severe pain, Approved October 2013 Wheelchair Clinic 17%>55 34 11/7/2014 Wheelchairs • Low turnaround from initial eval to delivery of WC • Solution ‐ W/C clinic 2nd Wed of the month – will start in November • Place consult for WC clinic – OT eval Same morning with rep – consult in PM&R office Goal to decrease eval to delivery of chair to < 40 days OK… So what is Cancer Rehab ? • Cancer rehabilitation is a specialty of physical medicine and rehabilitation that aims to meet these needs for cancer survivors. • Cancer rehabilitation plays a role throughout the continuum of cancer survivorship. 35 11/7/2014 ●Preventative rehabilitation –use of early intervention and exercise to prevent or delay complications related to cancer or its therapies. ●Restorative rehabilitation –full reintegration of the patient back into society, community, school, or work. ●Supportive rehabilitation –re‐establish functional independence as much as possible. ●Palliative rehabilitation –The goals are to maximize patient comfort and caregiver support. Role of the physiatrist ●A comprehensive functional assessment – ●Medication review – • thorough review of the patient’s medications is necessary to evaluate for drug‐related side effects that could be contributing to any presenting impairment • it is important to identify any potential drug interactions. ●Specific testing as indicated, including imaging, nerve conduction studies (NCS), electromyogram (EMG), or lab work. 36 11/7/2014 • referred to specialized services – – – – – prosthetics, orthotics physical therapy occupational therapy speech & swallow therapy lymphedema therapy) with a detailed prescription outlining their rehabilitation course. • Interventions may be recommended depending on the precise functional deficits encountered. Example –EMG guided Botox Examples • Head/Neck – Radiation Fibrosis, Drop Head Syndrome, Trismus, Spinal accessory nerve palsy • Shoulder – Lymphedema, Axillary web syndrome • Chest wall‐Postmastectomy pain syndrome (PMPS) • Aromatase Inhibitor associated Musculo‐ Skeletal Syndrome (AIMSS) • Chemotherapy‐induced neuropathy (CINP) 37 11/7/2014 Cancer Rehabilitation Memorial Sloan Keterring Cancer Center Micheal Stubblefield Christian Custodio Jonas Sokolof Cancer Rehabilitation Fellowship Residents from Columbia NYP Cancer Rehabilitation Programs have been started in : • • • • U‐Penn Medstar‐ National Rehab‐ Washington DC University of South Florida NSLIJ – Long Island, NY 38 11/7/2014 STARS The STAR Program® Certification (Survivorship Training and Rehabilitation) provide hospitals, cancer centers, group practices with the training, protocols and other tools needed to deliver evidence‐based “best practices” cancer rehab services. Closest to Dallas Methodist Richardson Cancer Center 16.4 miles Texas Health Presbyterian Hospital Plano 18.4 miles Baylor Sammons Cancer Center Dr. Preskitt & Group Surgical Oncology Services Time share in office to start November 17,2014 39 11/7/2014 Baylor Sammons Cancer Center Waxahachie • Dr. Reddy , Dr. Nair Will try to coordinate pt’s that would benefit from comprehensive cancer rehabilitation services 40 NON INVASIVE CARDIAC TESTING Rohit J. Parmar, M.D., F.A.C.C. Cardiology Consultants of Texas Asst. Professor of Med, Texas A&M College of Med. Baylor Scott & White OBJECTIVES: • Non invasive ischemic evaluation • Asymptomatic patient • Symptomatic patient • Testing • CAC • CTA • Treadmill exercise/ echo/ nuclear • Pharmacologic stress test • (Preop evaluation) $2.5 Trillion in health care cost for 2009 $2.5 Trillion in health care cost for 2009 $765 Billion waste • Unnecessary services • Fraud • Administration cost • Inefficiencies GEORGE BEST “I spent 90% of my time on women and drink – The rest I wasted” NON INVASIVE CARDIAC TESTS - STANDARD Standard tests: Exercise Tolerance Test (ETT) Imaging stress tests: Thallium/SestaMIBI Stress ECHO Pharmacologic stress tests NON INVASIVE CARDIAC TESTS – NEW Coronary calcium scoring CT coronary angiography Cardiac MRI and MRA EXERCISE TOLERANCE TESTS (ETT) Purpose: +/- CAD Assess level of functional capacity Risk stratification Arrhythmia assessment Cardiac rehabilitation EXERCISE TOLERANCE TESTS (ETT) Information desired: Duration of exercise (METS achieved) ECG changes: ST elevation/ ST depression HR/workload Clinical symptoms Max HR achieved Reason for test termination HR and BP response Arrhythmias EXERCISE TOLERANCE TESTS (ETT) ECG Changes EXERCISE TOLERANCE TESTS (ETT) Contraindications: Unstable angina Uncontrolled arrhythmias Poorly controlled HTN Severe AS Significant concurrent illness Mod-severe CHF EXERCISE TOLERANCE TESTS (ETT) Ways to improve test: Patient is well rested Can have small liquid breakfast ? AV nodal blocking agents EXERCISE TOLERANCE TESTS (ETT) Protocols available: Bruce Modified Bruce Naughton Modified Naughton etc. EXAMPLE ETT IMAGING MODALITIES Purpose: Increase S & S in the presence of: Poor exercise tolerance Abnl. baseline ECG ? Ischemia with borderline cath results IMAGING MODALITIES Myocardial Perfusion Imaging (MPI): Isotopes available: Thallium 201 (redistribution phase) Sesta MIBI Tc99 Teboroxime Tc99 Cannot eat between scans False (+) with LBBB, Dilated CM, IHSS, or infiltrative CM False (-) with 3V CAD Most common: Thallium rest + Sesta MIBI stress EXAMPLE THALLIUM + SM EXAMPLE IMAGING MODALITIES Stress ECHO: Same purpose as MPI S & S slightly less than MPI ECHO is more sensitive to chest wall abnl. Increased chest mass (breasts) Increased airspace (COPD) Difficult to predict IMAGING MODALITIES Advantages of Stress ECHO: (Full ECHO report) Cheaper Quicker Method of testing: Resting echo ETT Post-exercise ECHO image within 1 min. IMAGING MODALITIES Because S & S are fairly close, choice depends upon: Information desired Patient body habitus Cost Expertise of lab (VERY operator and equipment dependent) PHARMACOLOGIC STRESS TESTING Used primarily when patient is unable to perform adequate stress: Arthritis Severe deconditioning Illness Always used in combination with MPI or ECHO PHARMACOLOGIC STRESS TESTING Drugs available: Adenosine / Regadenoson (Lexiscan) (used only with MPI): Side effects: HA, N/V, CP/SOB Effects: Coronary vasodilator Minimal HR or BP change Ideal for LBBB NON INVASIVE CARDIAC TESTS - STANDARD Standard tests: Exercise Tolerance Test (ETT) Imaging stress tests: Thallium/SestaMIBI Stress ECHO Pharmacologic stress tests New tests: Coronary calcium scoring CT coronary angiography Cardiac MRI and MRA CT CORONARY CALCIUM SCORES CT of the chest without contrast Evaluates density of calcium deposits in the coronary arteries Calcium deposition roughly correlates to the severity and age of the atherosclerotic plaque formation Predictive of future cardiac events Does NOT correlate to severity of stenosis Cannot assess for the presence of ischemia CT CORONARY CALCIUM SCORES If you have high calcium scores, you have CAD. However, you do not know the severity. Early, soft plaque typically does not have significant calcium and will therefore not have high scores. Useful screening tool? ASYMPTOMATIC PATIENT • CT Coronary Calcium Score • Proven for prognostic value but not paid for by third party payers CORONARY ARTERY CALCIUM SCORE • Prognostic efficacy of CAC • CAC scanning for cardiac risk assessment • CAC scanning for cardiac risk management BUDOFF ET AL JACC 2007 DETRANO NEJM 2008 • Separated CCS pts • 3 fold increase in hazard ratio in patients with CCS 1-10 vs 0 NASIR & BUDOFF CT ANGIOGRAPHY CT of the chest with IV contrast. Attempt to provide data similar to coronary angiography. Useful when normal CT ANGIOGRAPHY Normal RCA CT ANGIOGRAPHY Comparison views of coronary angiograms and CT angiograms. CARDIAC MRI / MRA Data similar to CT angio Disadvantages: Slow Cannot have any metal in scanner Expensive Excellent for structural heart disease, e.g., congenital heart disease Not useful as a screening tool WHAT DO WE DO AS CLINICIANS? FRAMINGHAM RISK SCORE • Age • Gender • Total cholesterol • HDL • Smoker • BP (meds for BP?) RISK ASSESSMENT CHD Risk—Low Defined by the age-specific risk level that is below average. In general, low risk will correlate with a 10-year absolute CHD risk less than 10%. • CHD Risk—Moderate Defined by the age-specific risk level that is average or above average. In general, moderate risk will correlate with a 10-year absolute CHD risk between 10% and 20%. • CHD Risk—High Defined as the presence of diabetes mellitus in a patient 40 years of age or older, peripheral arterial disease or other coronary risk equivalents, or a 10-year absolute CHD risk of greater than 20%. • SYMPTOMATIC PATIENT Typical angina 1. Steady retrosternal component 2. Provoked by exertion or stress 3. Relieved by rest or NTG Atypical angina 2 of 3 criteria Non-anginal chest pain 1 of 3 criteria PRE TEST PROBABILITY •Very low pretest probability: Less than 5% pretest probability of CAD •Low pretest probability: Less than 10% pretest probability of CAD •Intermediate pretest probability: Between 10% and 90% pretest probability of CAD •High pretest probability: Greater than 90% pretest probability of CAD • FRAMINGHAM RISK SCORE • RISK ESTIMATOR • PRE-TEST PROBABILITY ASYMPTOMATIC PATIENT History Calculate pre-test probability Calculate FRS ASYMPTOMATIC PATIENT TEST - ?YES OR NO. IF YES, WHICH ONE? Standard tests: Exercise Tolerance Test (ETT) Imaging stress tests: Thallium/SestaMIBI Stress ECHO Pharmacologic stress tests New tests: Coronary calcium scoring CT coronary angiography Cardiac MRI and MRA CORONARY ARTERY CALCIUM SCORE Class II a indication • Asymptomatic with FRS 10-20% • Asymptomatic diabetics >40 years Class II b indication • Asymp in FRS 6-10% ASYMPTOMATIC PATIENTS Stress echo/ Stress MPI • High risk FRS – Unknown / Appropriate • Moderate risk FRS – Inappropriate • Low risk FRS - Inappropriate SYMPTOMATIC PTS - CP/ ANGINA EQUIVALENT • Generally speaking symptomatic patients can undergo ischemic evaluation “appropriately” • BUT which is the “appropriate” test – clinically relevant but cost effective WHAT IS AN APPROPRIATE STUDY? • An appropriate imaging study is one on which the expected incremental information, combined with clinical judgment exceeds the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication SUMMARY High No Symptoms CAC/ SE FRS Mod/ Low Yes None EKG Low No testing (ETT ongoing) High Cath/ Stress test Pre-test Probability Moderate Stress test Stress test Able to walk Yes Resting EKG LBBB ? ST Changes? Yes Stress echo or Stress MPI Yes No No Lexiscan MPI Or DSE Exercise EKG How far can we see? COURTROOM TESTIMONY COURTROOM TESTIMONY Attorney: So, you saw that did you? COURTROOM TESTIMONY Attorney: So, you saw that did you? Witness: Yes, I did COURTROOM TESTIMONY Attorney: So, you saw that did you? Witness: Yes, I did Attorney: That was pretty far from you. COURTROOM TESTIMONY Attorney: So, you saw that did you? Witness: Yes, I did Attorney: That was pretty far from you. How far can you see? COURTROOM TESTIMONY Attorney: So, you saw that did you? Witness: Yes, I did Attorney: That was pretty far from you. How far can you see? Witness: I can see the moon. How far is that? Ref: Jack Ziffer, M.D. Thank you for listening
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