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RPS Newsletter November 2010
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In This Issue:
New ACGME Requirements for PM
National Prevention Strategy
Prevention Spotlight
Case Report
Upcoming Events

ACGME Releases Revised PM Program Requirements

By Samuel Peik

The Accreditation Council for Graduate Medical Education (ACGME) recently released its new Program Requirements for Graduate Medical Education in Preventive Medicine.This represents the final version of the requirements, incorporating changes since the draft requirements were released last spring.The ACPM GME committee and RPS supplied official comments during this period, as well as numerous other individual PM physicians and residents.

 

One of the most significant changes include retention of the MPH degree requirement, which is a change from the draft recommendations earlier released.Other changes include 1) a minimum of 24 months of PM-specific training, 2) strengthening of the clinical clinical portion of training and 3) requirement of regularly scheduled didactic sections in core discipines.

 

The approved requirements will take effect July 1, 2011.ACPM has provided a brief summary of the changes in their latest Headlines newsletter. To view the new requirements in full as well as the ones currently in effect, visit the ACGME website at http://www.acgme.org/acWebsite/RRC_380/380_prIndex.asp.


Prevention Council National Strategy Takes Shape

ByCharlie Preston

As has been reported by ACPM before, the Affordable Care Act (ACA) creates a National Prevention, Health Promotion, and Public Health Council to shape national prevention strategy. The Council is chaired by the Surgeon General and includes high-level/ cabinet rank officials from 17 different federal departments, like the Department of Justice and the Department of Agriculture, who have a stake in prevention-related activities. In addition to an annual report, the Council is required to make public a National Prevention and Health Promotion Strategy-by March 23, 2011.

 

The Council has already begun its work on the Strategy. In fact, the Surgeon General convened the first face-to-face encounter of the principals in a September meeting at the White House. The national Strategy is also being worked on at a slightly lower level, through designee meetings, where representatives of the principal Council members have met to develop a framework for the Strategy.

 

On a recent stakeholder call with the Surgeon General, the framework was unveiled. It includes a draft vision, goals, and 10 strategic directions. The draft vision discusses moving the country from a health system focused on sickness to one focused on wellness. The draft goals have two prongs: 1) to create community environments that make the healthy choice the easy and affordable choice and, 2) to implement effective preventive practices. The 10 draft strategic directions are meant to frame actionable proposals to meet the vision and goals of the Council and to be a lens through which to view federal and non-federal activities.

 

The 10 strategic directions are:

  • Active lifestyles
  • Address specific populations' needs to eliminate health disparities
  • Counter alcohol/substance misuse
  • Healthy eating
  • Healthy physical and social environment
  • High impact quality and clinical preventive services
  • Injury-free living
  • Mental and emotional wellbeing
  • Strong public health infrastructure
  • Tobacco-free living

The Council will be conducting a robust public input process. To let them know what you think of the framework, visit: http://www.healthcare.gov/center/councils/nphpphc/.



Prevention Spotlight
by Samuel Peik

This new section provides a brief overview of current clinical preventive recommendations, including the United States Preventive Services Task Force (USPSTF) as well as other pertinent national organizations. This week's topic will focus on prostate cancer screening.

 

USPSTF: <75 yrs I (insufficient evidence); >75 yrs D (recommend against)

 

American Cancer Society (ACS): "informed decision with doctor", start at age 50 (45 for African Americans or + family history), use PSA

American Urological Association (AUA): "informed decision with doctor", start at age 40 with baseline PSA and DRE

 

For more on the USPSTF rating system, visit their website at http://www.uspreventiveservicestaskforce.org/.



Solution to September's Case Report
by Jordana Rothschild

Summary of case:

35 year old man with altered mental status, dilated pupils, fever, tachycardia, dry mucous membranes, and hypoactive bowel sounds.

Solution:
The patient's coworker brings you a bottle of pills she found on his desk, and you see that he has been taking amitryptiline for his chronic back pain.
You had correctly diagnosed him with anticholinergic toxicity.

Review:
Anticholinergic substances competitively antagonize acetylcholine muscarinic receptors; this predominantly occurs at peripheral (eg, heart, salivary glands, sweat glands, GI tract, GU tract) postganglionic parasympathetic muscarinic receptors.Central nervous system (CNS) manifestations result from central cortical and subcortical muscarinic receptor antagonism.

Presentation:
Remember common signs and symptoms with the mnemonic, "red as a beet, dry as a bone, blind as a bat, mad as a hatter, and hot as a hare." The mnemonic refers to the symptoms of flushing, dry skin and mucous membranes, mydriasis with loss of accommodation, altered mental status (AMS), and fever, respectively.Additional manifestations include sinus tachycardia, decreased bowel sounds, functional ileus, urinary retention, hypertension, tremulousness, and myoclonic jerking.Patients with central anticholinergic syndrome may present with ataxia, disorientation, short-term memory loss, confusion, hallucinations (visual, auditory), psychosis, agitated delirium, seizures (rare), coma, respiratory failure, and cardiovascular collapse.

Causes:
There are many agents with anticholinergic properties, including anticholinergics (scopolamine, atropine, glycopyrrolate, etc), antihistamines, antipsychotics, antispasmodics, cyclic antidepressants, mydriatics, and various plants.

Treatment:
Stabilize the patient until he can be transported to an emergency facility with ACLS capabilities; treat him as you would any patient with altered mental status.Gastric decontamination with activated charcoal is recommended if possible.Most patients will recover with supportive care after decontamination.

Sodium bicarbonate may be used to treat acidosis (often caused by tricyclic antidepressants), and has been anecdotally effective in treating antihistamine induced QRS prolongation (>100 ms) with a quinidinelike ECG pattern.

Administer a trial dose of physostigmine (only in a hospital setting) over 2-5 minutes for patients with narrow QRS supraventricular tachydysrhythmias resulting in hemodynamic deterioration or ischemic pain. Ventricular arrhythmias can be treated with lidocaine.

Manage seizures with benzodiazepines, preferably diazepam or lorazepam. Use phenobarbital and other barbiturates for intractable seizures.

Perform bladder catheterization if signs or symptoms of urinary retention exist.

The specific antidote for anticholinergic toxicity is physostigmine salycilate.Indications for use include tachydysrhythmias with subsequent hemodynamic compromise, intractable seizures, or severe agitation or psychosis (in which the patient is considered a threat to self or others).

For more information, see http://emedicine.medscape.com/article/812644-overview.


Upcoming Events
by M. Christine David


Fogarty Fellowship - Global Health and Clinical Research
(Application Deadline 11/19)
This is an opportunity for highly motivated individuals to experience mentored research training at top-ranked NIH-funded research centers in developing countries such as Bangladesh, Botswana, Brazil, China, Haiti, India, Kenya, Mali, Peru, Russia, South Africa, Tanzania, Thailand, Uganda and Zambia. Position descriptions and application materials can be downloaded from the ASPH-partner website, FICRS-F, at: http://fogartyscholars.org/news/2011-scholars-application-now-available.

Nuru International Fellows Program-Rolling Deadline
The Nuru International Fellows Program provides an opportunity for professionals to use their skills to affect real social change by working directly with communities in rural Kenya. The program offers opportunities in six different areas: agriculture; education; health care; water and sanitation; community economic development; and research.For more information, go to their website at http://www.nuruinternational.org/.

For more upcoming events, please visit ACPM's online calendar at http://www.acpm.org/calendar.htm.


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