HPV and Upper Aerodigestive Tract Cancers - OHSU

HPV and Upper

Aerodigestive Tract

Cancers Joshua Schindler, MD

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TThe Evidence for Current Cardiovascular Disease Prevention Guidelines:

Ineffective Therapies in Cardiovascular Disease

NEJMJACC

NEJMEpidemiology

Arch Intern Med Lancet Lancet NEJM

NEJMNEJM

Lancet Lancet JAMA

J Natl Cancer Inst

Arch Intern Med

NEJM BMJ

JAMA NEJM

NEJM JAMA

Cardiovasc Qual Outcomes JAMA

Carlo Patrono, Barry Coller, Garret A. FitzGerald, Jack Hirsh, and Gerald Roth

Financial Wellness:

Loan Repayment

Strategies for Medical

Professionals Justin Kribs, MS, CFP

Slides not provided

CirculationLancet Circulation

Lancet

When to initiate ARNI?

Initiation of an ARNI de novo without prior exposure to ACEI or ARB

Is use of aldosterone antagonistmandatory prior to using ARNI?

Circ Cardiovasc Qual Outcomes

Vaping, Nicotine

Addiction and Lung

Injury: The Smoke is

Lifting

Holger Link, MD

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The Lancet

The Lancet Diabetes & Endocrinology

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Unexpected Career Paths in MedicinePrimary Care Conference 2020

Portland, OR

Jessica Walter, M.A. | Steve Kinder, [email protected] | [email protected]

OHSU Division of Managementwww.ohsu.edu/management

What did you want to be when you were

six years old?

EDUCATION EXPERIENCE YOU!

Goals

You will leave here today withconcrete TOOLS

that you can start usingTODAY

to CREATE your futureand make better DECISIONS

Licensure AcademicAppointments

PositionRequirements

Licensure AcademicAppointments

PositionRequirements

Keep learning

Blind tasting Blind tasting

Informational interviews

Informational [email protected]

What are your strengths?What are my strengths?

When do you see me do my best work?

When are you energized?

Seek Opportunity Seek Opportunity

See Opportunity Run experiments

ProjectsCommitteesInterim roleSchoolVolunteer

Network Density

Ibarra, H. (2015). Act like a leader. Think like a leader. Harvard Business Press. pp 94 – 95.

Network Density

Ibarra, H. (2015). Act like a leader. Think like a leader. Harvard Business Press. pp 94 – 95.

Who is going to speak for me?

Carla Harris

https://www.ted.com/talks/carla_harris_how_to_find_the_person_who_can_help_you_get_ahead_at_work

Photo from

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J K J

C K J D C K J

D C K J Ghttps://www.bobsutton.net/books

Summary

1. Focus on purpose2. Find your gaps3. See(k) opportunities4. Build your team5. Build others

1. Meet three new people2. Conduct 1 informational

interview3. Craft 1 experiment 4. Connect 1 person to an

opportunity

To doVote now!

Finance 101Leadership StylesDesign ThinkingChange LeadershipPersonal Effectiveness

2019 ACC/AHA Primary Prevention

Guidelines SEAN ROBINSON, MD

OREGON HEALTH & SCIENCE UNIVERSITY

ASSISTANT PROFESSOR SPORTS & FAMILY MEDICINE

No conflict of interests

Preview Evidence

Patient Centered Approach to Comprehensive ASVCD Prevention

Team based Approach (COR I, LOE A) Shared decision making should guide discussions about best strategies to reduce ASCVD risk (COR I, LOE B-R)Social determinants of health should inform treatment recommendations (COR I, LOE B-NR)

Social Determinants of Health Income levelEducational opportunitiesOccupation, employment status, and workplace safetyGender inequityRacial segregationFood insecurity and inaccessibility of nutritious food choicesAccess to housing and utility servicesEarly childhood experiences and developmentSocial support and community inclusivityCrime rates and exposure to violent behaviorAvailability of transportationNeighborhood conditions and physical environment

Access to safe drinking water, clean air, and toxin-free environmentsRecreational and leisure opportunities

*Advanced age generally refers to age 75 years.ASCVD indicates atherosclerotic cardiovascular disease.

Assessment of Cardiovascular Risk

40-75 yo, routinely assess traditional cardiovascular risk factors and calculate 10-year risk of ASCVD using pooled cohort equations (COR I, LOE B-NR)20-39 yo, reasonable to assess traditional ASCVD risk every 4-6 years (COR IIa, LOE B-NR) Borderline risk (5%-7.5%) or intermediate risk ( 7.5% to 20%) reasonable to use risk-enhancing factors to guide therapy (COR IIa, LOE B-NR)In intermediate risk or selected adults at borderline risk, if risk-based discussion is uncertain, Coronary Calcium score is reasonable (COR IIa, LOE B-NR) 20-39 yo and 40-59 yo with ASCVD 7.5%, estimating lifetime risk may be considered (COR IIb, LOE B-NR)

Cohort equations

ASCVD Risk Estimator MESAFramingham CVD risk Reynolds SCORE QRISK/JBS3

Characterize Risk:

Low 5%

Borderline 5% to 7.5%

Intermediate 7.5% to 20%

High 20%

Summation

Coronary Calcium Score

Not a screening tool Helps further risk stratification/clarification

Intermediate risk Select borderline risk

CAC = 0 -> downward classification CAC 1-99 -> repeat risk discussion, ? Repeat test in 5 years CAC 100 (or 75% age/sex/race percentile) -> upward reclassification

My Take Away Points

10-year Risk assessment is the start of the conversation, not the end all be all Remember statins are not the only tool we have

Exercise, diet, sleep Use life-time risk as a tool to further the discussion (positive reinforcement or motivation to improve) Use risk-enhancers Use CAC to help clarify, demonstrate need/no need for therapy

Nutrition and Diet

Emphasize vegetables, fruits, legumes, nuts, whole grains, and fish (COR I, LOE B-R) Replace saturated fat with dietary mono/polyunsaturated fats (COR IIa, LOE B-NR)Reduce cholesterol and sodium in the diet (COR IIa, LOE B-NR) Minimize processed meats, refined carbohydrates, and sweetened beverages (COR IIa, LOE B-NR) AVOID trans fats (COR III, LOE B-NR)

Saturated vs Mono/polyunsaturated

Trans Fat

Eat real food

Exercise and Physical Activity

Counsel patients on optimization of living a physically active lifestyle (COR I, LOE B-R) Engage in 150 min/week of accumulated moderate intense exercise or 75 min/week of vigorous exercise in the form of aerobic exercise (COR I, LOE B-NR) Unable to meet the minimum abount above, engage in some moderate or vigorous intense exercise. This still can be beneficial. (COR IIa, LOE B-NR) Decreasing sedentary behavior may be reasonable to reduce ASCVD risk (COR IIb, LOE C-LD)

Intensity METs Examples

Sedentary behavior* 1–1.5 Sitting, reclining, or lying; watching television

Light 1.6–2.9 Walking slowly, cooking, light housework

Moderate 3.0–5.9

Brisk walking (2.4–4 mph), biking (5–9 mph), ballroom dancing, active yoga, recreational swimming

Vigorous 6Jogging/running, biking ( 10 mph), singles tennis, swimming laps

Sedentary behavior is defined as any waking behavior

characterized by an energy expenditure 1.5 METs while in

a sitting, reclining, or lying posture. Standing is a

sedentary activity in that it involves 1.5 METs, but it is not considered a component of

sedentary behavior.MET indicates metabolic

equivalent; and mph, miles per hour.

My Take Away

Please move Adults with Overweight and Obesity

Weight loss is recommended if overweight or obese (COR I, LOE B-R) Counseling and comprehensive lifestyle interventions, including calorie restriction, are recommended for achieving and maintaining weight loss (COR I, LOE B-R)Calculate BMI at least annually (COR I, LOE C-EO) Reasonable to measure waist circumference to identify those at higher cardiometabolic risk (COR IIa, LOE B_NR)

My Thoughts This can feel difficult to bring up and explore

Non-judgmental tone and listen to the patient and their prior failures

Ensure sleep is normal, I now rarely put much time and focus on weight loss if sleep is not buttoned up Everybody who is overweight knows they need to lose weight Stay away from fads Do not overload with recommendations or suggestions

Chose low hanging fruit, first Make goals reasonable and doable

Use motivational interviewing skills

Adults with Type 2 Diabetes Mellitus (DMII)

A tailored nutrition plan focusing on a heart-healthy dietary pattern is recommended to improve glycemic control, achieve weight loss if needed, and improve other ASCVD risk factors (COR I, LOE A) Exercise at least 150 minutes per week of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity (COR I, LOE A) Initiate metformin as first-line therapy along with lifestyle therapies at the time of diagnosis to improve glycemic control and reduce ASCVD risk (COR IIa, LOE B-R)Reasonable to initiate a sodium-glucose cotransporter 2 (SGLT-2) inhibitor or a glucagon-like peptide-1 receptor (GLP-1R) agonist to improve glycemic control if above does not help (COR ILb, LOE B-R)

Risk-Enhancers in Diabetic Patients

Long duration ( 10 years for T2DM or 20 years for type 1 diabetes mellitus) Albuminuria 30 mcg albumin/mg creatinine eGFR <60 mL/min/1.73 m2 Retinopathy Neuropathy ABI <0.9

My Thoughts

DMII can be reversed!!Use diet, exercise and sleep to helpMetformin is first line pharmacologic treatment Use and know the risk-enhancers for DMIISodium-glucose cotransporter 2 (SGLT-2) inhibitor or a glucagon-like peptide-1 receptor (GLP-1R) for second line pharmacologic treatment

Adults with High Cholesterol

Intermediate risk ( 7.5% to <20% 10-year ASCVD risk) a moderate-intensity statin should be recommended (COR I, LOE A)In intermediate risk ( 7.5% to <20% 10-year ASCVD risk) patients, LDL-C levels should be reduced by 30% or more, and for optimal ASCVD risk reduction, especially in patients at high risk ( 20% 10-year ASCVD risk), levels should be reduced by 50% or more (COR I, LOE A)40 to 75 yo with DMII, regardless of estimated 10-year ASCVD risk, moderate-intensity statin therapy is indicated (COR I, LOE A)20 to 75 yo with an LDL-C level of 190 mg/dL or higher, maximally tolerated statin therapy is recommended (COR I, LOE B-R)DMII who have multiple ASCVD risk factors, it is reasonable to prescribe high-intensity statin therapy with the aim to reduce LDL-C levels by 50% or more (COR IIa, LOE B-R)Intermediate-risk ( 7.5% to <20% 10-year ASCVD risk) adults, risk-enhancing factors favor initiation or intensification of statin therapy (COR IIa, LOE B-R)

In intermediate-risk ( 7.5% to <20% 10-year ASCVD risk) adults or selected borderline-risk (5% to <7.5% 10-year ASCVD risk) adults in whom a CAC score is measured for the purpose of making a treatment decision, AND

CAC = zero, it is reasonable to withhold statin therapy and reassess in 5 to 10 years, as long as higher-risk conditions are absent (e.g., diabetes, family history of premature CHD, cigarette smoking); CAC = 1 to 99, it is reasonable to initiate statin therapy for patients 55 years of age; CAC = 100 or higher or in the 75th percentile or higher, it is reasonable to initiate statin therapy (COR IIa, LOE B-NR)

Borderline risk (5% to <7.5% 10-year ASCVD risk), the presence of risk- enhancing factors may justify initiation of moderate-intensity statin therapy (COR IIb, LOE B-R)

My Thoughts

Use a 10-year risk calculator for most patients Print/easy access to the flowsheetStatins are our friendsCAC can be helpful Patient-centered discussion are key to help communicate risk

Adults with Hypertension

Elevated blood pressure (BP) or hypertension, including those requiring antihypertensive medications nonpharmacological interventions are recommended to reduce BP. These include:

weight loss heart-healthy dietary pattern sodium reduction dietary potassium supplementationincreased physical activity with a structured exercise programlimited alcohol (COR I, LOE A)

10-year ASCVD risk of 10% or higher and an average systolic BP (SBP) of 130 mm Hg or higher or an average diastolic BP (DBP) of 80 mm Hg or higher, use of BP-lowering medications is recommended (COR I, LOE SBP: A, DBP: C-EO)In adults with confirmed hypertension and a 10-year ASCVD event risk of 10% or higher, a BP target of less than 130/80 mm Hg is recommended (COR I, LOE SBP: B-R, DBP: C-EO)In adults with hypertension and chronic kidney disease, treatment to a BP goal of less than 130/80 mm Hg is recommended (COR I, LOE SBP: B-R, DBP: C-EO)

In adults with T2DM and hypertension, antihypertensive drug treatment should be initiated at a BP of 130/80 mm Hg or higher, with a treatment goal of less than 130/80 mm Hg (COR I, LOE SBP: B-R, DBP: C-EO)In adults with an estimated 10-year ASCVD risk <10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher, initiation and use of BP-lowering medication are recommended (COR I, LOE C-LD)

In adults with confirmed hypertension without additional markers of increased ASCVD risk, a BP target of less than 130/80 mm Hg may be reasonable (COR IIb, LOE SBP: B-NR, DBP: C-EO)

Table 7. Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension*

Nonpharmacological Intervention Goal

Approximate Impact on SBP

Hypertension Normotension

Weight loss Weight/body fat

Best goal is ideal body weight, but aim for at least a 1-kg reduction in body weight for most adults who are overweight. Expect about 1 mm Hg for every 1-kg reduction in body weight.

-5 mm Hg -2/3 mm Hg

Healthy diet DASH dietary pattern†

Consume a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat.

-11 mm Hg -3 mm Hg

Reduced intake of dietary sodium Dietary sodium

Optimal goal is <1500 mg/d,, but aim for at least a 1000-mg/d reduction in most adults.

-5/6 mm Hg -2/3 mm Hg

Enhanced intake of dietary potassium Dietary potassium Aim for 3500–5000 mg/d, preferably by

consumption of a diet rich in potassium. -4/5 mm Hg -2 mm Hg

Physical activity

Aerobic 90–150 min/wk65%–75% heart rate reserve -5/8 mm Hg -2/4 mm Hg

Dynamic resistance90–150 min/wk50%–80% 1 rep maximum6 exercises, 3 sets/exercise, 10 repetitions/set

-4 mm Hg -2 mm Hg

Isometric resistance

4 × 2 min (hand grip), 1 min rest between exercises, 30%–40% maximum voluntary contraction, 3 sessions/wk8–10 wk

-5 mm Hg -4 mm Hg

Moderation in alcohol intake

Alcohol consumption

In individuals who drink alcohol, reduce alcohol‡to:Men: 2 drinks dailyWomen: 1 drink daily

-4 mm Hg -3 mm Hg

My Thoughts

Lifestyle changes help120-129/ is Elevated Blood Pressure – formally known as Prehypertension Calculate ASCVD risk if found to have Hypertension (10% is cut off for medications)

140/90 -> Start medication

Treatment of Tobacco Use

Assess tobacco use at every visit and their tobacco use status; record as a vital sign to facilitate tobacco cessation (COR I, LOE A) Firmly advised to quit tobacco use (COE I, LOE A) A combination of behavioral interventions plus pharmacotherapy is recommended to maximize quit rates (COE I, LOE A) Tobacco abstinence is recommended to reduce ASCVD risk (COE I, LOE A) It is reasonable to dedicate trained staff to tobacco treatment in every healthcare system (COE IIa, LOE B-R) All adults and adolescents should avoid secondhand smoke exposure to reduce ASCVD risk (COE III, LOE B-NR)

My Thoughts

Tobacco is still REALLY bad for you Help your patient quit, bring it up often (every visit) Many options out there to help 1-800-Quit-Now

Aspirin (ASA) Use

Low-dose aspirin (75-100 mg orally daily) might be considered for the primary prevention of ASCVD among select adults 40 to 70 years of age who are at higher ASCVD risk but not at increased bleeding risk (COR IIb, LOE A) Low-dose aspirin (75-100 mg orally daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults >70 years of age (COR III, LOE B-R) Low-dose aspirin (75-100 mg orally daily) should not be administered for the primary prevention of ASCVD among adults of any age who are at increased risk of bleeding (COR III, LOE C-LD)

My Thoughts

Avoid ASA usuallyThere still is a place for ASA in certain low risk patients These guidelines are for PRIMARY not secondary prevention

Simple 7

Top 10 Messages 1. Healthy lifestyle promotion is KEY to prevent ASCVD, heart

failure, atrial fibrillation 2. Use a TEAM and social determinants of health should help

guide informed treatment decisions. 3. 40-75 yo should undergo a 10 yr ASCVD risk estimation.

Followed by a risk discussion before starting medications. Risk -enhancing factor may help in this conversation.

4. CONSUME A HEALTHY DIET! Mostly Plants and real food. Weight loss strategies through calorie restriction should be applied for obese patients.

5. MOVE! 150 min/week of moderate intense exercise (75 min/week for vigorous)

6. DMII -> LIFESTYLE change. Metformin first followed by SGLT2 or GLP-1

7. Assess TOBACCO at every visit and advise to QUIT8. ASA for primary prevention should be used seldom9. STATIN is first line Tx for LDL >190, DMII, and at high risk for

ASCVD10. Target BLOOD PRESSURE is <130/80 mm Hg, Lifestyle is

first line treatment

Thank You

NEONATAL CHOLESTASIS GUIDELINES

DATE: 8 Nov 2019 PRESENTED BY: Jonathan Q. Purnell, MDProfessor, Knight Cardiovascular InstituteOregon Health & Science UniversityPortland, Oregon

The Skinny on PharmacologicManagement of Obesity

Weight Curve

Weight Management: Chronic DiseaseModel

Body Weight Set Point Receives Signalsfrom Gut Hormones During Meal

CNS Body Weight Regulation Center ReceivesAdiposity and Meal related Signals


Obesity is associated with >230 complications

Yuen et al. Obesity Week 2016; Poster T-P-3166


Question

Weight LossComparison of“Named Diets.”Dansinger, et al. JAMA2005;293:43 53.

Diabetes Prevention Program: Modest Effecton Weight (Low fat Diet + Exercise)N Engl J Med 346:393–403, 2002.

Diabetes Incidence Best Lowered by Lifestyle(Low fat Diet + Exercise)N Engl J Med 346:393–403, 2002.

Lifestyle Recommendations


Recommendation For Consideration ofPharmacological Weight Management

Pharmacological Weight Management Pharmacological Weight Management

Weight Loss Medications Enhance CNSSignaling to Meal related Signals

Weight Loss With PhentermineMonroe, et al. BMJ. 1:352 54. 1968. Phentermine: Side Effects and Precautions

Weight Loss with Phentermine + Topiramate(Qsymia)Garvey WT, et al. Am J Clin Nutr. 2012;95:297 308.

Cardiovascular Safety During and After Use ofPhentermine and TopiramateRitchey ME, et al. J Clin Endocrinol Metab. 2019, 104(2):513–522

Weight Loss With Lorcaserin (5 HT2C agonist)Bohula EA et al. N Engl J Med 2018;379:1107 1117

Non inferiority of Lorcaserin (5 HT2C agonist) onMACEBohula EA et al. N Engl J Med 2018;379:1107 1117

Weight Loss With Buproprion + Naltrexon (Contrave)Nissen SE, et al. JAMA. 2016;315(10):990 1004.

Effect of Buproprion + Naltrexon (Contrave) on MACENissen SE, et al. JAMA. 2016;315(10):990 1004.

Liraglutide 3.0 for Weight Management and Type2 Diabetes Risk Reduction in Pre diabetesle Roux, et al. Lancet 2017; 389: 1399–409

Liraglutide 3.0 for Weight Management andType 2 Diabetes Risk Reduction in Pre diabetesle Roux, et al. Lancet 2017; 389: 1399–409

LEADER: Liraglutide 1.8 mg Improves CardiovascularOutcomes and All Cause Mortality in Type 2 DiabetesMarso SP et al. N Engl J Med 2016;375:311 322.

Weight Curve Weight Curve

Weight Curve: Next Steps Weight Curve: Next Steps

Question Weight Curve: Example of Using Rx forWeight Stability

Weight Curve: Example of Using Rx forWeight Stability

Weight Curve: Example of Using Rx forWeight Stability

Think management of hypercholesterolemia before statins and hypertension before ACEI

Patient is a non-responder (a “responder” may maintain weight)

Side effect(s) emerge

BMI 35 kg/m2 + comorbidityBMI 40 kg/m2

Reasons for Underutilization ofWeight Management Medications

Thank You

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Eur Heart J

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J Clin Lipidol Pharmacist's Letter.

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J Clin Lipidol N Engl J Med

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Mayo Clin Proc.

N Engl J Med.

Thank You

HPV and Upper Aerodigestive Tract Cancers - OHSU

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