Emerging Challenges in Primary Care: 2014

Transcription

1 Emerging Challenges In Primary Care: 2014 Activity Evaluation Summary CME Activity: Emerging Challenges in Primary Care: 2014 Saturday, September 13, 2014 Hilton Sacramento Arden West Sacramento, CA Course Director: Gregg Sherman, MD Date of Evaluation Summary: October 3, NW 70th Avenue Plantation, Florida (954) Phone (954) Fax

2 In September 2014, the National Association for Continuing Education (NACE) sponsored a CME program, Emerging Challenges in Primary Care: 2014, in Sacramento, CA. This educational activity was designed to provide primary care physicians, nurse practitioners, physician assistants and other primary care providers the opportunity to learn about varied conditions such as Diabetes, Resistant Hypertension, Alpha-1 Antitrypsin Deficiency, Idiopathic Pulmonary Fibrosis, LUTS and Overactive Bladder. In planning this CME activity, the NACE performed a needs assessment. A literature search was conducted, national guidelines were reviewed, survey data was analyzed, and experts in each therapeutic area were consulted to determine gaps in practitioner knowledge, competence or performance. One hundred forty one healthcare practitioners registered to attend Emerging Challenges in Primary Care: 2014 in Sacramento, CA and One hundred sixty two registered to participate in the live simulcast. One hundred eighty healthcare practitioners actually participated in the conference: ninety five attended the conference in Sacramento, CA and eighty five participated via the live simulcast. Each attendee was asked to complete and return an activity evaluation form prior to the end of the conference. One hundred forty four completed forms were received. The data collected is displayed in this report. CME ACCREDITATION The National Association for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The National Association for Continuing Education designates this live activity for a maximum of 7.0 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity. National Association for Continuing Education is approved as a provider of nurse practitioner continuing education by the American Association of Nurse Practitioners. AANP Provider Number This program has been approved for 7.0 contact hours of continuing education (which includes 3.25 hours of pharmacology).

3 What is your professional degree? MD 90 63% DO 8 6% NP 25 17% PA 12 8% RN 4 3% Other 5 3% Total MD DO NP PA RN Other What is your specialty? Primary Care % Endocrinology 3 2% Rheumatology 0 Pulmonology 0 Cardiology 3 2% Gastroenterology 1 1% Other 27 19% Total

4 Indicate the number of patients you see each week in a clinical setting regarding each therapeutic area listed: Diabetes: None 15 11% % % % % % > % Total % 2 15% 1 5% None > 25 Indicate the number of patients you see each week in a clinical setting regarding each therapeutic area listed: Hypertension: None 13 9% % % % % > % Total % 2 15% 1 5% None > 25

5 Indicate the number of patients you see each week in a clinical setting regarding each therapeutic area listed: Alpha-1: None % % % % % > 25 0 Total None > 25 Indicate the number of patients you see each week in a clinical setting regarding each therapeutic area listed: IPF: None 73 55% % % % % > 25 0 Total None > 25

6 Indicate the number of patients you see each week in a clinical setting regarding each therapeutic area listed: OAB: None 23 17% % % % % > % Total None > 25 Indicate the number of patients you see each week in a clinical setting regarding each therapeutic area listed: LUTS: None 28 21% % % % % > % Total None > 25

7 Upon completion of this activity, I can now: Identify the barriers between physicians and patients to discussing and initiating injectable treatments for diabetes; Discuss the role of incretin therapies in the management of type 2 diabetes; Describe how best to initiate, utilize and intensify insulin therapy in patients with diabetes; Recognize the role of combining GLP-1 analogs with insulin to individualize care, achieve targets and minimize hypoglycemia: Yes % Somewhat 22 16% Not at all 1 1% Total Yes Somewhat Not at all Upon completion of this activity, I can now: Describe the burden of resistant hypertension; Discuss the clinical work-up of resistant hypertension, including approaches to rule out secondary (reversible) causes; Recognize the importance of 24- hour ambulatory blood pressure monitoring for the diagnosis of resistant hypertension; Employ effective combinations of lifestyle interventions and pharmacotherapy to maximize BP control in patients with resistant hypertension: Yes % Somewhat 17 12% Not at all 1 1% Total Yes Somewhat Not at all

8 Upon completion of this activity, I can now: Review the 50-year history of alpha-1 antitrypsin (AAT) deficiency; Identify who and when to test for AAT deficiency; Discuss how to incorporate testing for AAT deficiency into everyday practice; Describe the new insights into the efficacy of treatment for AAT deficiency: Yes 99 71% Somewhat 36 26% Not at all 4 3% Total Yes Somewhat Not at all Upon completion of this activity, I can now: Discuss the appropriate strategy for the diagnosis of idiopathic pulmonary fibrosis (IPF), Recognize prognostic features for individual IPF patients; Appreciate the optimal timing for referral of IPF patients to specialty referral centers; Discuss appropriate pharmacotherapeutic options for individual IPF patients; Recognize the role of available non-pharmacological therapies including pulmonary rehabilitation, oxygen supplementation and lung transplantation in IPF management: Yes % Somewhat 27 2 Not at all 5 4% Total Yes Somewhat Not at all

9 Upon completion of this activity, I can now: Recognize the role of simple questioning for identifying patients with overactive bladder (OAB); Discuss the essential components of the evaluation of the patient with OAB symptoms; Develop a management plan for patients with OAB that emphasizes the incorporation of behavioral therapy and setting appropriate expectations, optimizes efficacy and minimizes side effects to improve patient compliance and adherence with pharmacologic therapy; Describe the role of recently approved second line therapies, third line therapies and future therapies in patients with OAB who are unsatisfied with antimuscarinic therapy: Yes % Somewhat 12 9% Not at all 3 2% Total Yes Somewhat Not at all Upon completion of this activity, I can now: Understand that lower urinary tract symptoms in a male could be caused by medical issues, the bladder or the prostate and that a simple history and physical can help delineate the problem; Recognize that erectile dysfunction (ED) and BPH share many of the same co-morbidities; Discuss the different classes of medications available for OAB and BPH; Recognize the risk factors for progression of BPH: Yes % Somewhat 14 11% Not at all 3 2% Total Yes Somewhat Not at all

10 Overall, this was an excellent CME activity: Strongly Agree % Agree 40 28% Neutral 0 Disagree 0 Strongly Disagree 0 Total Strongly Agree Agree Neutral Disagree Strongly Disagree Overall, this activity was effective in improving my knowledge in the content areas presented: Strongly Agree % Agree 38 27% Neutral 0 Disagree 0 Strongly Disagree 0 Total Strongly Agree Agree Neutral Disagree Strongly Disagree As a result of this activity, I have learned new and useful strategies for patient care: Strongly Agree 89 63% Agree 51 36% Neutral 2 1% Disagree 0 Strongly Disagree 0 Total

11 Strongly Agree Agree Neutral Disagree Strongly Disagree How likely are you to implement these new strategies in your practice? Very Likely 96 69% Somewhat likely 30 21% Unlikely 2 1% Not applicable 12 9% Total Very Likely Somewhat likely Unlikely Not applicable When do you intend to implement these new strategies into your practice? Within 1 month 88 64% 1-3 months months 5 4% Not applicable 17 12% Total Within 1 month 1-3 months 4-6 months Not applicable

12 In terms of delivery of the presentation, please rate the effectiveness of the speaker: Mark Stolar (Diabetes): Excellent % Very Good 28 2 Good 4 3% Fair 0 Unsatisfactory 1 1% Total Excellent Very Good Good Fair Unsatisfactory In terms of delivery of the presentation, please rate the effectiveness of the speaker: Jan Basile MD (Hypertension): Excellent % Very Good 25 18% Good 5 4% Fair 1 1% Unsatisfactory 0 Total Excellent Very Good Good Fair Unsatisfactory

13 In terms of delivery of the presentation, please rate the effectiveness of the speaker: Arunabh Talwar, MD (Alpha-1): Excellent 83 63% Very Good 31 23% Good 15 11% Fair 2 2% Unsatisfactory 1 1% Total Excellent Very Good Good Fair Unsatisfactory In terms of delivery of the presentation, please rate the effectiveness of the speaker: Arunabh Talwar, MD (IPF): Excellent 90 7 Very Good 28 22% Good 7 5% Fair 2 2% Unsatisfactory 1 1% Total Excellent Very Good Good Fair Unsatisfactory In terms of delivery of the presentation, please rate the effectiveness of the speaker: Matt Rosenberg, MD (OAB): Excellent % Very Good 12 9% Good 3 2% Fair 0 Unsatisfactory 1 1% Total

14 10 5 Excellent Very Good Good Fair Unsatisfactory In terms of delivery of the presentation, please rate the effectiveness of the speaker: Matt Rosenberg, MD (LUTS): Excellent % Very Good 9 7% Good 4 3% Fair 0 Unsatisfactory 1 1% Total Excellent Very Good Good Fair Unsatisfactory To what degree do you believe that the subject matter was presented fair, balanced, and free of commercial bias? Mark Stolar, MD (Diabetes): Excellent % Very Good 25 18% Good 7 5% Fair 2 1% Unsatisfactory 1 1% Total Excellent Very Good Good Fair Unsatisfactory

15 To what degree do you believe that the subject matter was presented fair, balanced, and free of commercial bias? Jan Basile, MD (Hypertension): Excellent Very Good 20 15% Good 6 4% Fair 0 Unsatisfactory 1 1% Total Excellent Very Good Good Fair Unsatisfactory To what degree do you believe that the subject matter was presented fair, balanced, and free of commercial bias? Arunabh Talwar, MD (Alpha-1): Excellent 95 74% Very Good 21 16% Good 9 7% Fair 2 2% Unsatisfactory 1 1% Total Excellent Very Good Good Fair Unsatisfactory

16 To what degree do you believe that the subject matter was presented fair, balanced, and free of commercial bias? Arunabh Talwar, MD (IPF): Excellent 96 79% Very Good 17 14% Good 6 5% Fair 1 1% Unsatisfactory 1 1% Total Excellent Very Good Good Fair Unsatisfactory To what degree do you believe that the subject matter was presented fair, balanced, and free of commercial bias? Matt Rosenberg, MD (OAB): Excellent % Very Good 16 13% Good 3 2% Fair 0 Unsatisfactory 1 1% Total Excellent Very Good Good Fair Unsatisfactory

17 To what degree do you believe that the subject matter was presented fair, balanced, and free of commercial bias? Matt Rosenberg, MD (LUTS): Excellent % Very Good 13 1 Good 4 3% Fair 0 Unsatisfactory 1 1% Total Excellent Very Good Good Fair Unsatisfactory Which statement(s) best reflects your reasons for participating in this activity: Topics covered % Location/ease of access 94 27% Faculty 29 8% Earn CME credits % Total % 3 25% 2 15% 1 5% Topics covered Location/ease of access Faculty Earn CME credits

18 Future CME activities concerning this subject matter are necessary: Strongly agree 79 56% Agree 46 33% Neutral 15 11% Disagree 1 1% Strongly Disagree 0 Total Strongly agree Agree Neutral Disagree Strongly Disagree As a result of this activity, I have learned new strategies for patient care. List these strategies: Comment -Best therapy to consider for IPF -Differentiating between urinary obstruction & OAB -OAB-The benefits of a voiding diary 1-Review current practice of medication combining regimens, time frames f/u for DM & HTN treatments/management/education. 2-Optimize appropriate diagnostics in dx & treatment of IPF, OAB & Prostate diseases. 3-Changed focus & practice on prostate size, urinary retention/fu & treatments/diagnostics. Add injection early with Diabetes Alpha antitrypsin screening. IPF diagnosis - CT scan. LUTS, OAB, diagnosis and Rx. Injectables in diabetes Alpha-1 IPF LUTS already practice this way good review Am retired - but plan to restart oncology Applying the methods learned today Approach patients re injectables Approach to over active bladder and treatment of diabetes Ask patients more in depth history questions. Assessing for resistant hypertension, assessing for OAB and LUTS, discussing injectable therapies with patients as good treatment option, not to be feared Avoid overtreating patients with IPF

19 Better communication about initiating needles for DM treatment Better understanding of IPF and treatment Better treatment of OAB issues Overall great review and great information to better my practice. better treatment management options in manning patients with HTN and OAB Checking white coat hypertension, using nursing staff to teach the use of injectables, the use of injectables in diabetes Consider testing for AADT. Consider early combo treatment for BP. DDX of AAT deficiency lung condition Diagnosis and treatment and approach Diagnosis and treatment of diabetes and Alpha-1A deficiency Diagnostic criteria Management Discuss Gliptons with patient and break down patient barriers to injections Discuss the risk of insulins with patients Do not be timid in introducing injectable therapy in DM, listen to concerns, consider chlorithalidone more in BP control in ambulatory BP to diagnosis, COPD, think screening for alpha, AT, diagnosis and treatment of OAB/LUTS Don't wait to start injectable therapy to control DM. Excluse pseudoresistant hypertension. All COPD patients should be screened for AATD. Teach OAB patients how to void Earlier initiate injection for diabetes. Ambulatory BP monitors. Aware of AAT. Consider in every COPD patient/younger patient testing Earlier use of insulins for GLP in DM. Search for causes of apparent resistant hypertension. Screen for AAT deficiency. Do not use steroids for IPF Early insulin initiation is critical for improving glycemic control and perhaps delaying or preventing complications. Early start of injections in diabetic control. Screen ALL COPD for AAT deficiency Early use of GLP and insulin therapy. Optimal strategies to start injection therapy for diabetes; use of aldesterone antagment, optimal strategies to identify and treat resistant hypertension; OAB - better communication with patient Early use of injectable for DM. Using GLP-1 injectable with insulin. Prevalence of resistant HTN Educate patients early use of injectables therapies Evaluating resistant increased BP for confounding factors such as 'white coat', noncompliance. Screen young emphysemics of AAT Following guidelines and recommendations How and when to adjust diabetes medicatons How to effectively initiate injectables with uncontrolled diabetes and push for more patient education for compliance and better outcome. Help me to use BP drugs for resistant HTN How to identify patient with AAT, treat resistance hypertension, use injectables How to treat BPH and overactive bladder. Resistant hypertension. Injectable therapy for diabetes I am more comfortable starting injectable meds for diabetes earlier. Using long acting insulin but also injectable noninsulin meds. Talking to pt about fears and overcoming use. I was reminded of the medications to use for htn and looking for causes of resistence. Thinking of Alpha 1 in young patients with copd.

20 Using different medications for OAB in men and women. I currently work exclusively in urology and was/am currently using the strategies discussed in the OAB & LUTS lectures. I do not treat hypertension, pulmonary disease or diabetes so will not be using any new strategies in areas I do not treat. I attended this lecture to keep updated on other specialties and conditions. I have a limited clinical practice. I enjoy the on line exposure to current medical practice. I like to stay current and know what others are doing in these challenging areas. I learned diabetic patients are not that resistant to be started on injections if doctors explain to them the reasons and benefits of good glucose control. I learned about the characters of IPF, progression, prognosis and treatment. I learned new ways to treat OAB and LUTS. Identify resistant HTN. Screen AAT deficiency Identifying risk factors in each disorder Explaining advantage of each diabetes drug Offer support to patients with OAB in addition to appropriate medication choice If I were in clinical practice, I would have a list of more decisive questions to ask patients regarding the discussed topics. Most lectures gave great algorhytms to use when developing a care plan. Implant the diabetic to plan Importance of asking the patient for more info rather than expecting them to tell me Running more tests Better focus on history with clinical date Improve recognition of IPF. Improved treatment for DM. Improved treatment of HTN patients Improved H&p, Kandahar patient compliance In resistant hypertension remember to look for pseudo resistant hypertension which accounts for 5 of those who appear to be resistant. In all the topics the patient's history is vital. All patients have to be examined. In prostate cancer the rectal examination is very important. Communicating with doctor and the patient, and keep it simple and effective in treatment, and learn to be safe. Incorporate rehab for management of ipf. Increase use GLP1 injectable DMI. Remind patient value of bedtime antitrypsin. Evaluate sleep apnea. Use ABPM. OAB - many new options info esp on the DM meds/and the OA Diff/tx Initiate injectable therapies for DM. Recognize and treat resistant HTN Identify and test for AAT deficiency Identify and treat patients with OAB Initiating insulin early is essential. White coat syndrome occurs approximately 33% of the time and should be taken into account. injectable insulins Injection of insulin patients self self adjusting dosage titration big help. Screen all my COPD patients with frese test. BP control for ABPM very good Insulin therapy. HTN approach. Using screening for AAT Oct. Treatment of IPF Learned to teach voiding hygiene Make the patient partner in care DM. HTN ACE/ARB diuretic CCB - 1 BIB except MI/CHF. AATD test early. OAB indications and communication. IPF DX S DX-PVX CT-AD. LUTS prostate bladder GI other

21 Monitor emphysema More aggression in treating type II DM regarding injectables. Screening COPD patients for Alpha-1 antitrypsin deficiency. Screening resistant hypertension More aggressive in insulin therapy and diagnosing IPF. More aggressive in treating HPTN MORE CONCENTRATED EVALUATION more frequent testing for alpha 1 More use of GLP-1 agents when appropriate. Stop try to teach device use - have nurse/educator teach. Screen all COPD patients for alpha-1 antitrypsin deficiency much more likely to use injectables in treating diabetes. Never use insulin as a threat 500 rule and 1800 rule estimate prostate size using psa New approaches to DM management Treating resistant HTN Identifying OAB & LUTS NEW LABS TEST FOR ALPHA 1 DEFICIENCY IMPROVED THE DIAGNOSTIC APPROACH FOR LUTS CHANGE MY THERAPEUTIC APPROACH FOR DM TO CHANGE THE APPROACH WHEN OFFERING INJECTABLE DRUGS FOR DM TO BETTER ACCESSS COPD PATIENT AT RISK FOR FIBROSIS New strategies. Intensity management Not sure ok Overall good review Patient education Effective and skilled communication Meaningful follow-up care Patients with IPF - screening. Strategy of treatment of hypertension. OD Bladder Prescribing more GLP 1 meds with diabetes along with Insulin Ordering of ALPHa 1 antitrypsin levels when they are needed and went to refer them Public health screening for AATD to promote increased awareness on the scale of celiac disease and cystic fibrosis Reasons to use injectable insulin sooner rather than later, options with LUTS, OAB potential treatments, screen for IPF with SOB and/or cough with chest x-ray and PFT, recognize resistant hypertension, screen for AAT with patients with COPD Retired. Baseline insulin for DM and add if dinner glucose increases and GLP add. No ACE with ARB. AAT - lower lobe emphysema, cias - upper Screen all COPD for AATD. How to treat OAB. Diagnose OAB versus BPH Screen for AAT deficiency. Screen for white coat syndrome. Start GLP-1 treatment Screen for AATD Screen for Alpha-1 AATD Screen patients more regularly. Integrate patient in care planning. Stress exercise benefit Screening for alpha, antitrypsin deficiency Strategies for intensifying insulin with rule of 1800/500. Trial of 1 anti-htn drug AHS if not in control. OAB is all about urgency of small amounts of liquid (volume) Take complete history

22 Testing all COPD and liver disease patients for AAD. How to better control resistant HTN with chlorithalidane/spivercilactone That the risk of alpha 1 deficiency is greater than what people think and individuals should be tested more frequently. the importance of obtaining a good history from the pt. ensuring a complete, up to date drug list at each office visit appropriate, timely office visit. Therapy on treatment of AAT Think of adding GLP; do not be hesitant at starting insulin. Think of testing for AAT in COPD patients. Think of AAT in patients with lower extremity - panniculitis Think screen for AAT Thinking Thinking about AATD in my COPD patients. Treating resistant hypertension To have diabetics test FBS first. When better control then 3 times per week at different times of the day. To recognize glucotoxicity and treat aggressively. Know which agent to add as 4M agent in RH To treat and manage alpha 1, LUTS, OAB, IPF, HTN, DM Treatment of resistant hypertension. Treatment of diabetes Individualizing care Understanding Use injectables in DM. Screening COPD patients for AAT deficiency. Strategies for identifying and treating patients with resistant HTN, disease of IPF, treatment of OAB and LUTS Use of GLP-1 analogues. Proper testing of patients with resistant HTN. Treatment OAB Use of glp1 and basal insulin Ask more about urinary symptoms Start screening for aat Weakness in urinary flow, think of prostate problem. Poor voiding volume, check for bladder problem White coat syndrome in HTN. Increase salt intake. No need for bladder scan Will not test for AAT deficiency, start injectable diabetic treatment earlier, discuss IPF with one patient I have with it, pay attention to PSA relation prostate size Will use incretin therapy and insulin together more. Will not accept treatment IPF. Will screen and consider alpha/antitrypsin deficiency Will use this guideline in our office Wonderful explanation with real cases What topics would you like to see offered as CME activities in the future?

23 Comment AFIB osteoarthritis back pain ADD, ADHD from childhood to adulthood. End of life situations & medical decisions & family care during those hard times. prescription drug abuse Address the barriers to compliance and how to overcome it ADHD, DSM 5 analysis Antiplatelet Rx in CHD any and all Any that facilitate preventive medicine practices & latest disease management that ate most cost effective to public & practice. Arthritis treatment Asthma Depression Obesity Eating Disorders Autoimmune thyroiditis. HCV treatment. How to deal with Obamacare and treating patient confidence Bariatric surgery Bipolar disorder, depression, schizophrenia Can never get enough of diabetes treatment! Cancer - breast and prostate especially. Women's Health Cardiology for primary care physicians Cardiopulmonary exercise testing. Pulmonary/cardiac rehab Celiac disease. Transplantation immunology. Emerging infectious diseases Cervical cancer CHF. Atrial Fibrillation. Stroke. Sepsis Cholesterol management, psychiatry drugs for primary care Congestive heart failure. Coronary artery disease COPD - patients with recurrent bronchitis. Dermatitis Decreasing cost of health care. Increasing coverage to more Americans Depression, Alzheimer's, Bipolar, Obesity Depression, IHD Dermatology in primary care Diabetes - screening tests for general population for cancers DIABETES ON LIMITED DRUG FORMULARIES INSTITUTION ACUTE HEPATITIS COAGULOPATHIES THYROID CONDITIONS UPDATES GUIDELINES ON PRIMARY CARE Diseases of the heart EHR documentation and Reimbursement Hospital readmissions Endocrine emergencies, AAT adrenal insufficiency, pheochromagtomas, MEA, Thyroid Storm, Myxedema Coma, DKA, NKHC, Hyper parathyroidism, Hypoparathyroidism, Hyperkalemia, Hyponatremia, SAIDH Erectile dysfunction, chronic kidney disease, proteinuria, hypertension update, Evaluate and treat seizure disorders. Difficult headache patients Excellent programs and speakers. Very convenient to have simultaneous webcam.

24 genetics Gyn issues, neuropathy, cardiac issues, pain management GYN-hormones. Asthma Having looked into activities lists available at CME on the website all needs for learning are there Heart diseases Hep SCD Rx. Topics in GI Hepatitis. OBGYN HIV prophylactic treatment. HCV prophylactic treatment HTN, Dyslipidemia, mental health issues in primary women's health Hyperlipidemia management Hyperlipidemia. Depression/anxiety for Primary Care providers injectable drug treatments for osteoporosis inpatient radiology - xrays and ct nutrition support for patients with questions about fad diets chronic kidney disease Insulin Resistance, PCOD, Infertility, Insomnia, Anxiety, Depression Integrative Medicine Learning more about herbal affects in primary care Joint injections Kids obesity. Group teaching of diabetes Lipid management. CKD management Management of HTN urgency, emergency More about DM, HTN latest and greatest care. Summaries of best Cancer screening. More diabetes more diabetes more diabetes.. asthma pt with variety of illness PLUS they are pregnant approaches to care of folks with autism More on HTN and DM management Muscle-skeletal. Chronic back pain (or pain in general). Headache management Neurotransmission of psychiatric disease New approaches to diabetes manangement. Next step... hospice, how to have that conversation. Musculoskeletal issues, LBP, TIA. How to prevent a stroke (as much as possible). Cancer screening, the gray areas, PSA, CA-125, etc obesity diabetes depression copd Obesity, CAD, dermatology for primary care, chronic low back pain, pain management Obstructive sleep apnea disease to treatments. NASH - disease and treatment Opioid-induced constipation osteoporosis Osteoporosis, depression/anxiety, hyperlipidemia Osteoporosis. Controversial treatment. Explain office based PFT in cahlinc stress test usage at office The surgical home personality disorders

25 psych disorders STD, women's health, depression, panic attack, female sexual dysfunction Thyroid, liver diseases treatment bipolar and review on new medications. Pediatric topics of any kind. Type 1 diabetes Hyperlipidemia treatment Vitamin D deficiency diagnosis and treatment Hypogonadism Ulcerative colitis Pancreatic cancer Urgent care problems Value of bariatric surgery. Dyslipidemia Vitamin D - test or not to test, just replace? Osteoporosis; chronic pain treatment therapy; preventive screening guidelines update (vaccines, PSA, colon cancer, mammo/pap) Womans health issues sexually transmitted diseases womens healthcare Wound care. Ankle porachial index interpretation. PVD Additional comments: Comment Decent lunch Diabetes lecture was great Dr. Talwar deserves congratulations. He is an excellent speaker. Thoroughly enjoyed this lecture Dr. Talwar is excellent. He made the IPF topic ideas Dr. Talwar was excellent but barely audible Enjoyed audience participation type programming Excellent conference Excellent conference. Thank you Excellent faculty Excellent presentations especially the very entertaining last speaker Excellent program Excellent program and speakers Excellent speaker Excellent talks. Full of information Free parking would be helpful FYI: I'm a new FNP and am waiting to get my first job... so that is why I but "none" to pts... but I LOVE the convience of LIVE webinar... PLUS the pre/post questions were great... plus your panel was great... like the UROlogy person, he made it fun esp how to urinate properly :) Good valuable topics Good review of latest updates. Great CME Great CME. Loved it Great conference. The smaller settings help me Great program Great meeting overall

26 I always enjoy and learn from these type programs. It was a great experience looking forward to do more of them. Locations - East Bay locations in San Francisco bay areas Music played between question and answer period distracting Overall great lectures and informative Staying on time is important. Thank you for staying on time Thank you for an excellent program Thank you for bringing this CME to Sacramento. It was a great experience. Come back next year Thank you for the nice lectures/topics Thank-you Thanks! The enthusiasm of the speakers regarding topics and their ability to make the lecture simple and interesting made this a worthwhile and fruitful experience The notes followed well with the speakers This was a long day but very fruitful and worthwhile, thank you Very good and beneficial CME Very good course, very good speakers What a great conference. Really appreciate it.