#ProudtobeGIM

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We had a great #proudtobeGIM lunch at UASOM yesterday, with an amazing panel of diverse general internists, a room full of interested and engaged students, and free lunch! As I reflect on the career journeys of my colleagues, I was struck by my own path.

Once I figured out medical school was the right direction for me, it was always primary care.  Joel Fleischman, perhaps more than any other fictional character, was always my inspiration.  Well trained, bright, and then immersed in a community, perhaps a small one, where you get to know EVERYONE. Take care of whole families, and see your patients at the grocery store.maxresdefault

Over the course of medical school, “primary care” became General Internal Medicine.  I picked medicine over family practice because I really enjoyed the complexity of adult patients with multiple chronic diseases, and saw that I could have a real impact in that group of people. It has given me the long-term relationships that I craved early on. And I  still get to treat families.  I have often been “auditioned” by the mom, who then refers her adult children, husband, sister, neighbor….  It is quite an honor when I pass muster.  And I see my patients at the grocery store, park, and most frequently when I’m sitting down to a cheeseburger, fries, and a milkshake. Doctors, they’re just like us!

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What took my by surprise was my love for teaching. Once I became a ward resident, I realized that breaking complex topics down to explain to others was a lot like giving advice to patients, and sometimes even more fun. Not only did I learn things more deeply after teaching them, I got to forge these great relationships with my colleagues. But primary care was still my goal. I wasn’t going to do a fellowship, and I wasn’t a chief resident, so I didn’t think academic medicine would be in the cards for me. Until a mentor approached me about interviewing for a position in GIM. I think that I actually said, “Really? Y’all would hire me?!

I interviewed for private practice groups and for GIM at UAB, and it became clear that I was much more excited about teaching and administration than I ever would have thought during my preclinical years.  Everyone I work with does something different, which really gives me a feeling that the sky is the limit. Certainly I have to earn my salary, but I can take my career in so many directions.  I have opportunities to get more training in education, QI, research techniques, leadership, and more.  And the “earning my salary” part- seeing patients and teaching residents in clinic, is pretty great. I love my job now, and I love the possibilities for the future.

All of this makes me incredibly Proud to be GIM!

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SGIM Proud to be GIM website

Follow us on Facebook and Twitter  @UABGIM

Join us at Cantina Tortilla Grill (Pepper Place) on Jan 18th @ 5:30 for Food, drink, and more great insights on GIM as a career path.

 

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Pneumonia shots- part 1: Patients over 65

In my ever continuing struggle to stay up to date, i thought I’d post today about something that was big news back in the Fall: Two pneumonia shots for seniors.

The old news was that everyone needed a pneumonia shot at age 65- one and done, we always thought.  That “pneumonia shot” was really a vaccine against S. Pneumoniae, which causes meningitis, sepsis, along with the pneumonia that it was so nicely named for.  The standard vaccine that we used in adults was the 23-Valent polysaccharide vaccine (PPSV23), brand name Pneumovax.  This vaccine covers 23 serotypes of S. pneumoniae (that’s the 23 valent part of the name), and is made from polysaccharides found in the capsules of the bacterium (that’s the polysaccharide part of the name).  This shot is great because it covers so many different serotypes.  The downside of polysaccharide vaccines is that they can’t be given in children <2, they don’t provide lifelong immunity, and they don’t provide mucosal immunity (important because mucosal immunity promotes herd immunity). Studies on this vaccine show that it can prevent invasive pneumococcal disease, but may not be so great at preventing the noninvasive pneumococcal pneumonia.

These “polysaccharides” come from the S. pneumoniae capsule.

Enter the 13 Valent Conjugate Vaccine (PCV13), brand name Prevnar. This still uses polysaccharides from the pneumococcal bacteria, but attaches (conjugates) them to a “carrier protein”– in this case, a protein from diptheria. This carrier protein helps to rev up the immune system and induces mucosal immunity.  After several exposures, this kind of vaccine will induce lifelong immunity.  Before this year, we were commonly using this kind of vaccine in children (since the other one didn’t work), and in immunocompromised adults, but not in everyone.  We know from this vaccine, and another conjugate pneumonia vaccine (PCV7), that immunizing children reduces the prevalence of those particular serotypes in adults (remember, mucosal immunity is a key to creating herd immunity).

The new news is that the PCV13 is now recommended for all adults >65.  This recommendation came on the heels of a study performed by Pfizer (you can guess what they make) in the Netherlands.  They studied 85,000 adults >65 who had never had a pneumococcal vaccine, and compared PCV13 to Placebo.  There was a 75% reduction in vaccine-type pneumococcal disease in the vaccine group, and a 45% reduction in vaccine-type CAP.  This was convincing enough for ACIP (the group that makes vaccine schedule recommendations).  It is important to say again: participants in the study DID NOT have PPSV23 prior to the PCV13. Many of our patients have already had PPSV23.

We do know that PCV13 does induce an immune response in seniors, even if they have already had the PPSV23.  It seems to be a “higher” immune response than the PPSV23, indicating that it may be the better vaccine between the two.

So what to do?  Currently ACIP recommends that we give BOTH PCV13 and PPSV23 to our patients over 65.  The ideal scenario would be to give the PCV13 (Prevnar) first, and then the PPSV23 (Pneumovax) 6-12 months later. This is what you should do for patients who have never had any pneumococcal vaccination, as well as those who you are revaccinating because they have turned 65.  If your patient over 65 has already had PPSV23, then wait a year before giving the PCV13. See the handy chart below for potential scenarios

Pneumococcal vaccine status:

FIRST give:

THEN give:

None/Unknown

Prevnar 13
(≥ age 65)

Pneumovax 23

(6 to 12 months after Prevnar 13)

Pneumovax 23
Given AFTER 65
th birthday

Prevnar 13
(≥ 12 months after Pneumovax 23)

n/a

Pneumovax 23
Given BEFORE 65
th birthday

Prevnar 13

(≥ age 65 AND

≥ 1 year after Pneumovax 23)

Pneumovax 23
(6 to 12 months after Prevnar 13 AND
5 years after Pneumovax 23)

So what about paying for these vaccines?  That is another sticky situation. Medicare currently pays for ONE S. Pneumonia vaccine per lifetime– which now seems to run counter to ACIP guidelines.  It will take a year or two for Medicare to catch up, so don’t expect this to change until about 2016. *UPDATED INFO: Medicare, BCBS and Viva are in fact paying for the PCV13 vaccine.  My read of the Medicare website shows that the second pneumococcal vaccine will be covered if it is given 11 months after the first one.  If your patient is new to Medicare, or hasn’t had any S. pneumoniae vaccines yet, give them the PCV13– it is more immunogenic and is better to give first.  If your patient has already gotten a PPSV23 while covered by Medicare, they will likely have to pay out of pocket ($100-$150) to get the PCV13.  My advice is to wait until the Medicare guidelines catch up. After that, wait a year or so and give the PPSV23.  If they have already had the PPSV23, then give the PCV13 the next year.  It is safe to give the second shot as early as 8 weeks after the first one.

Here are some practice scenarios. Let me know which vaccine you would give, when, and why in the comments.

  1. 65 year old, no medical problems, never had a S. Pneumoniae vaccine
  2. 75 year old, Medicare patient, vaccinated with PPSV23 at age 65
  3. 65 year old with diabetes, new to Medicare, got PPSV23 at age 59 after diagnosis with DM

If you are ready to move on to Part 2, take a look at this post.

Here’s a link to the CDCs Adult Vaccine Schedule- note the new guideline for adults age 65 and over is not included here, yet.  There’s also an app for that.

Unicorn Sighting

Happy guideline season!

I’ve been hearing about JNC 8 for so long, that I thought it didn’t really exist.  Thanks to some persistent hypertension experts, it is here at long last.  Here’s a quick review of the major points. I’m sure that we will see some commentary in the days and weeks to come, I’ll try to keep you updated on that as well.   I’d love to hear what you think- start the conversation in the comments below.

Higher BP targets

We are used to aiming for 140/90 for most people, and 130/80 for those with CKD, diabetes, CAD, and other comorbidities.  But new evidence  has emerged that these may not be so great, particularly for elderly patients.  So JNC 8 says- Adults 18-60 (even with DM or CKD) should aim for BP <140/90.  We can be a little more relaxed with patients over 60, and aim at 150/90 for them, so long as they don’t have CKD or DM.  Most of this change comes because there really was no outcome data for our prior target, and it seems that getting people to the 140s systolic provides just as much benefit as the 130s range.

Relaxed first line medicine choices

We’ve known that this was coming for a while.  JNC 7 recommended thiazides as first line for all, but there was never any real data to back that up.  So JNC 8 says that we can use thiazides, ACE-I/ARBs, or calcium channel blockers as a first choice for most patients.  They do acknowledge the racial difference in response to ACE inhibition, and recommend that we DON’T use ACE/ARB as first line for our black patients. EXCEPT (there’s always an exception) that for patients with chronic kidney disease (but not necessarily diabetes without ckd), use ACE-I first, no matter the race.

Second, and third, and fourth line medicines

Really not much different here, except there are not really recommendations about when to start two medicines at first visit.  JNC 8 says we can pick a variety of treatment strategies– maximize one medicine at a time, add a second agent before maximizing the first, or start two medicines at once.  When you add agents; pick from that first line list (thiazides, ACE/ARB, CCB) until you’ve used them all, then use aldosterone antagonists, beta blockers, central agents, or other vasodilators.  They do recommend avoiding ACE-I and ARB combos for most patients.

What’s Missing

JNC 7 discussed prehypertension, secondary hypertension, resistant hypertension, adherence, how to measure blood pressure, and lots of other related issues. The JNC 8 group just picked 3 questions that they felt were most important: does starting treatment at a particular threshold improve outcomes, does a particular treatment goal improve outcomes, do various drugs have important differences in risk/benefit calculation and outcomes.  Very evidence based and outcome oriented, which is kind of refreshing.

What about my patients now?

For all of us who have been trying to follow JNC 7 (and the subsequent performance measures created from that guideline), should we go adjusting therapy on our patients to meet new targets?  No, say these experts.  If your patient has a blood pressure of <150/90 on their current therapy, and is doing well, no need to change. Stay tuned to see if any of our performance targets change.

A great big picture algorithm from the JNC 8 group is here, and the link to the guidelines themselves is here (on the JAMA website subscription may be needed).

Here’s a great, plain language summary from the NYT Well blog.