|08-19-2002, 01:32 PM||#1|
30th Annual Physician Assistant Conference:
30th Annual Physician Assistant Conference:
Pearls, updates, and clinical highlights from Boston
Jump to: Choose article section...Make the most of physical therapyAbdominal pain in the elderly: A danger signalPearls of remote and rural primary careUnderstanding the place of ANA testingProblems unique to skin of colorLiving longer with cystic fibrosisHeart-health guidelines you can use
Julia Russell, Joyce O'Connor, and Jeff Forster contributed to this article.
At the end of May, more than 7,100 PAs, students, and other health care professionals gathered for the AAPA's 30th Annual Physician Assistant Conference at Boston's Hynes Convention Center and adjacent hotels. Deliberations in the House of Delegates centered on Academy support for federal funding of stem cell research (see below) and other emerging issues of importance to PA practice.
Stem cell research: Summary of a clinical white paper from the AAPA's Clinical and Scientific Affairs Council
Stem cell research holds great promise for a better understanding of developmental biology and for its potential applications to clinical medicine. New therapies for spinal cord injury, neurodegenerative diseases, transplantation, diabetes, and other chronic illnesses may ultimately be developed from such research.
Stem cells are precursor cells that can give rise to multiple cell types. In normal human development, a fertilized egg undergoes several cell divisions to form the blastocyst, a hollow sphere of cells. The cells that develop within this core, the inner cell mass (ICM), become the germ layers (endoderm, mesoderm, and ectoderm) from which virtually all cell types are derived within the developing organism. Extracting the ICM cells and growing them in cell culture while preventing differentiation maintains their potential to develop into multiple cell types in the correct microenvironment.
The technology to isolate and grow human stem cells has recently been developed. Stem cells have been grown from fertilized eggs donated from in vitro fertilization procedures, gonadal and mesenteric cells in fetal tissue, adult somatic stem cells (eg, hematopoietic bone marrow cells), and somatic cell nuclear transfer to an enucleated donated ovum. A fertilized egg or zygote is totipotent and is capable of developing into a whole organism. Embryonic stem cells are pluripotent and can develop into any germ cell type, while adult somatic cells are multipotent and differentiate into fewer cell types.
Potential clinical applications of stem cell technology have been seen in the successful transplantation of glial derivatives in rat models of multiple sclerosis with partial remyelinization and of spinal cord injury with a partial functional recovery. Transplantation of embryonic stem cells into injured organs may regenerate tissues in the pancreatic islet cells of patients with diabetes; cardiac myocytes after myocardial infarction; or hepatocytes in chronic liver disease. However, immunologic rejection of cell transplantation will continue to be an issue unless somatic cell nucleus transfer techniques provide for immunologic tolerance.
Currently, most stem cell research utilizes cell lines developed from discarded and donated fertilized eggs from in vitro fertilization procedures. Adult stem cell and somatic cell nuclear transfer techniques hold the promise of cell lines with fewer bioethical questions than does the use of embryonic or fetal tissue. The development of pluripotent and multipotent stem cell lines that may produce many tissues of the human body is an important scientific breakthrough.
PAs need to monitor the development of this dynamic field of research to further their understanding of developmental biology as well as for the potential clinical applications it may produce.
Here, JAAPA looks at but a handful of the 300 CME sessions offered at this year's conference. The meeting, which drew PAs from across the nation, included everything from hands-on workshops to adjunct symposia to poster sessions of original PA research (abstracts of selected research are online at www.jaapa.com ).
Make the most of physical therapy
How can physical therapists (PTs) allow you to spend more time with your patients? Marty Caudle, PA-C, PT, of Washington University School of Medicine, said that PTs are good at patient education and spending time with patients. PTs can evaluate and treat a wide variety of musculoskeletal and neurologic disorders with a number of modalities; establishing a relationship with the PTs in your area will help you know who has specialty training, as in the treatment of back pain. PTs can specialize in disciplines such as orthopedic/sports and manual therapy, neurorehabilitation, in-hospital acute care, long-term care in nursing homes and home health, and pediatrics.
When writing a prescription for physical therapy, include the diagnosis, the frequency and duration of therapy, and a description of what should be treated. You can also specify the type of treatment (eg, ultrasonography, heat therapy) or any restrictions on treatments. If you have a long-term relationship with the PT, writing "evaluate and treat" on the prescription gives the PT legal latitude to treat the patient as appropriate, without first calling you. Remember that a so-called physical therapy diagnosis applies only to billing codes, not to a medical diagnosis. PTs can't treat another part of the body without your order, nor can they extend the duration of treatment beyond your prescription without first contacting you.
Abdominal pain in the elderly: A danger signal
Abdominal pain in the elderly is often a life-threatening emergency, rendered more elusive-and more sinister-by a presentation that is often atypical or seemingly benign.
"The clinical picture is usually complicated by the extensive comorbidities that are characteristic of this rapidly growing segment of the population," said Richard E. Wolfe, MD, chief of emergency medicine at Beth Israel Deaconess Medical Center in Boston. Clinicians should remain especially alert for abdominal aortic aneurysm, bowel perforation, ischemic bowel, sigmoid volvulus, diverticulitis, cholangitis, and underlying cancers.
One of the biggest errors in treating these patients is a delay in surgical evaluation and intervention, which can be fatal. Such delays are often the result of poor history taking and lack of careful physical examination in combination with an atypical presentation and an uncommon etiology.
"One of the hardest things in emergency medicine," Dr. Wolfe said, "is to determine who is sick and who isn't." To help in that determination, he suggested a number of steps:
• Check vital signs, recognizing that BP in an older patient can be normal up until the time the patient crashes.
• In taking the history, ask which came first-abdominal pain or vomiting? Vomiting first is a more reassuring finding.
• Determine which medications the patient is taking and whether he or she has previously had abdominal surgery.
• Is the pain only below the umbilicus? If it's also above, you'll need to rule out extra-abdominal causes.
Bedside ultrasonography, performed by the emergency provider, can serve as a screen to help direct and optimize the use of further imaging studies and to shorten the time until surgical evaluation and intervention. "An ultrasound examination is never negative," Dr. Wolfe noted. "You can't use it to rule something out, but you can use it to rule something in."
Pearls of remote and rural primary care
PAs who choose to serve in remote and rural places must have more than basic PA education, says Gerry Keenan, PA-C, MMS, who practices at a clinic in the far reaches of Maine. Adjunct training is essential-in advanced cardiac and pediatric life support, prehospital trauma life support, and in wilderness medicine. The most valuable skills are reading x-rays, administering ECGs, performing lab tests, and preparing a patient for transport-sending a critically ill or injured patient to a specialist or hospital may take many hours.
A family medicine PA in a remote clinic may be the only provider for many patients. A solid library of medical texts is a necessity, and a network of mentors and colleagues who can be contacted quickly for assistance or referral is essential. A solo practitioner relies on the telephone, radio, and computer-and, when available, telemedicine. Medical supplies should include plenty of antibiotics, pain medication, antiseptics, and splinting materials. Medical emergencies often necessitate improvisation with materials on hand; for example, splinting with cardboard (always have some), carpet foam, and duct tape. Document everything!
Rural employment or volunteer opportunities can be found through the National Health Service, at Native American health sites, and in recreational and resort areas.
Understanding the place of ANA testing
Antinuclear antibodies (ANAs) are nonspecific immunoglobins directed against a variety of nuclear antigens and are generally associated with autoimmune disease such as systemic lupus erythematosus (SLE), SjÃ¶gren's syndrome, scleroderma, polymyositis, dermatomyositis, rheumatoid arthritis, and vasculitis. Up to 10% of the population, however, may have ANAs present without evidence of a systemic, inflammatory autoimmune disease. So, what's the value of ANA testing?
Scott Vogelgesang, MD, of the University of Iowa, told a packed room that a positive ANA test in the absence of clinical findings does not confirm the diagnosis of an autoimmune disease. The history, physical exam, and other labs should be used to identify or rule out disease.
Dr. Vogelgesang recommends ordering an ANA test only if the history, physical exam, and baseline laboratory tests suggest an autoimmune disease. ANA is useful in excluding a diagnosis of SLE but is not a screening test for this disease because the prevalence of SLE is 10 to 50 per 100,000 persons and the prevalence of ANA is 5,000 to 10,000 per 100,000. An anti-Sm test or dsDNA may be useful when SLE is suspected; although anti-Sm is 95% specific for SLE, it is only 30% to 40% sensitive. Consider a rheumatology referral if automimmune disease is suspected or if the patient is anxious about the condition.
Problems unique to skin of color
Although dark-skinned persons have less skin cancer and less pronounced photoaging, they are more prone to pigmentation disorders, they have a greater incidence of keloid formation, and the curved hair follicles and spiral hair type common among African-Americans leave them more prone to pseudofolliculitis and to scalp and facial disorders.
Paula F. Moskowitz, MD, PhD, of Roger Williams Medical Center in Providence, RI, discussed common dermatologic concerns of dark-skinned persons. Melasma, an acquired, symmetrical dark brown hyperpigmentation on the face and arms, is seen in Asian, Hispanic, and Mediterranean skin types and is caused by sun exposure, hormonal factors, and genetics. Sunscreen and sun avoidance are cornerstones to treatment. Mild cases can be treated with sunscreen, hydroquinone (a bleaching agent), glycolic acid, or azelaic acid. Moderate or severe cases can be treated with sunscreen, hydroquinone, or azelaic acid, plus tretinoin and a topical corticosteroid.
Acne hyperpigmented macules-dark spots-have a profound psychological impact on persons with dark skin. Dark spots may take years to clear up after the acne lesion resolves. These dark spots are often the patient's chief complaint. Therapy for mild acne includes a topical retinoid (adapalene [Differin] gel or cream, or tretinoin 0.2% cream) plus benzoyl peroxide 2.5% to 3.0%, a topical antibiotic lotion, or azelaic acid cream. An oral antibiotic can be added for moderate acne. Evaluate the patient for the use of a systemic retinoid in severe cases.
Pseudofolliculitis barbae appears in African-American and Hispanic men and women who have helical or spiral hair shafts. After hair is removed with shaving, waxing, or tweezing, the new hair curves back into the follicle as it grows, acting as a foreign body and producing an inflammatory response that causes perifollicular papules and pustules. Prevention is the best approach to this problem. Advise the patient not to shave, tweeze, or wax for as many as 6 months to allow resolution. When the condition resolves, the patient can begin hair removal again-but using a warm compress or a polyester web sponge to release the hair and using electric clippers, a so-called bump-fighter razor, an electric rotary razor, or a chemical depilatory. Above all, the patient should not use twin- and triple-blade razors. Adjunctive treatment includes a topical or systemic antibiotic along with topical glycolic or lactic acid, a retinoid, hydrocortisone, or a chemical peel.
Living longer with cystic fibrosis
Of the approximately 25,000 persons living in the United States with cystic fibrosis (CF), two thirds are adults. The median lifespan for a person who has CF is 32.5 years, said Beryl Rosenstein, MD, director of the Cystic Fibrosis Center at Johns Hopkins Hospital in Baltimore, Md.
A variety of clinical manifestations are seen, including chronic and recurrent sinusitis and nasal polyps, chronic endobronchial infection, airway obstruction, and chest film abnormalities in the lower respiratory tract (eg, bronchiectasis, infiltrates, hyperinflation). CF should be suspected in malabsorption characterized by frequent bulky and malodorous stools; poor weight gain, often despite adequate caloric intake; recurrent or chronic respiratory tract manifestations (cough, wheeze, sputum, tachypnea, pneumonia); persistent sinusitis; or salt depletion and dehydration. Less frequently, CF is suggested by pancreatitis, liver disease, intussusception, appendiceal disease, or male infertility. The presence of one or more characteristic clinical features, a history of CF in a sibling, or a positive newborn screening test warrants a diagnostic test.
A patient who has CF should be followed by a primary care provider in conjunction with a clinician at a center that specializes in CF. Patients should receive all the usual childhood immunizations, plus pneumococcal vaccine and annual influenza vaccine. Oral hypoglycemic agents are not usually effective in controlling diabetes in a person who also has CF, and insulin should be used instead. Increased fluid intake and added salt in the diet are important in CF, especially with exercise, heat exposure, and fever. Patients with CF should maintain an exercise regimen.
Patients are usually seen every 3 months at the CF center, where clinical status is monitored by periodic health assessments, including anthropometric measurements, lab tests, respiratory tract culture, chest radiography, and pulmonary function tests. A patient who has CF may require pancreatic enzyme and vitamin supplements, an increased caloric intake (up to 150% of energy recommendations for growth), and an H2-blocker or a proton pump inhibitor for gastroesophageal reflux and esophagitis. Airway clearance is maintained using manual chest physical therapy (eg, drainage, percussion, vibration), a therapy vest, and positive expiratory pressure devices. The CF armamentarium includes mucolytic agents, antibiotics, bronchodilators, anti-inflammatory agents (including inhaled and oral glucocorticoid agents and high-dose ibuprofen), and supplementary oxygen.
Heart-health guidelines you can use
More than one third of all Americans have high cholesterol levels, according to Christine Werner, PA-C, PhD, RD, of Cardiology Consultants in Belleville, Ind. How can clinicians teach patients to eat in a healthier way and devise strategies to help these patients stay within nutritional guidelines?
Updated dietary guidelines from both the American Heart Association and the National Cholesterol Education Program use the US Department of Agriculture guidelines as a foundation. The AHA focuses on preventing heart disease by emphasizing food selection rather than percentages or nutrients; looking at one's total lifestyle; maintaining a healthy overall diet, weight, lipid levels, and BP; and eating complex carbohydrates, whole grains, fish, lean meats, and low-fat or fat-free dairy products.
The NCEP guidelines focus on achieving and maintaining healthy blood cholesterol levels by reducing dietary saturated fats and cholesterol, consuming plant stenols and sterols (2 g/d) and soluble fiber (10-25 g/d), reducing weight, and increasing physical activity. The NCEP recommends a total blood cholesterol level of less than 200 mg/dL, an HDL level at or above 60 mg/dL, and an LDL level less than 100 mg/dL. The guidelines should be individualized to the patient's risk factors and therapeutic needs as well as to his or her readiness for lifestyle change.
Julia Russell. 30th Annual PA Conference: Pearls, updates, and clinical highlights from Boston. JAAPA 2002;7:44-49.
Copyright Â© 2002, Medical Economics Company, Inc. and the American Academy of Physician Assistants. Published by Medical Economics Company, Inc. at Montvale, NJ 07645-1742. All rights reserved.
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