#173 Hotcakes: Imposter syndrome, Vacations & metabolic syndrome, Pneumonia vaccine update, and More!

September 16, 2019 | By Sarah Phoebe Roberts

Dr Kimberly Manning joins for Back-to-school cakes edition September 2019

Dr Kimberly Manning joins to discuss imposter syndrome, how vacations affect health, and an update on the pneumonia vaccine, PCV13. Plus, hot takes on the dangers of vaping, and using procalcitonin and CRP to determine need for antibiotics.

Howdy, gentle listeners! It’s that special time of year when the school doors reopen, classrooms are awash in ‘new pencil’ smell, and FOAMed fans grab their trays and head to the cafeteria for some tasty knowledge food. Rest assured your Curbsiders friends have saved you a seat at the lunch table for this very special September 2019 episode!

Today we are joined by Dr. Kimberly Manning MD, FACP, FAAP, who is an Associate Professor of Medicine at Emory University School of Medicine. Dr. Manning authors a blog (“Reflections of a Grady Doctor”) that was named in 2010 by ‘O’ The Oprah Magazine as one of “four top medical blogs you should read.” She can also be found on Twitter, @gradydoctor. Thanks for listening!

Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Credits 

Written and Produced by: Sarah Phoebe Roberts MPH, Christopher Chiu MD, FACP, FAAP

Hosts: Matthew Watto MD, FACP; Sarah Phoebe Roberts MPH, Paul Williams MD, FACP; and Christopher Chiu MD, FACP, FAAP

Editor: Christopher Chiu MD, FACP, FAAP; Emi Okamoto MD

Cover-Art: Christopher Chiu MD, FACP, FAAP

Guest: Kimberly Manning MD, FACP, FAAP

Time stamps

• 00:00 Introduction/Disclaimer
• 03:15 Guest bio
• 05:00 Getting to know Dr. Manning
• 11:05 Picks of the week*: Reflections of a Grady Doctor, Dr. Kimberly Manning’s Blog; To Kill a Mockingbird by Harper Lee, audiobook narrated by Sissy Spacek; LeVar Burton Reads, a podcast; Aziz Ansari Right Now (comedy special) and Master of None (TV show); Garfield Minus Garfield, an existential take on a classic comic; Clue, the 1985 movie
• 17:15 Paul’s vaping update (CDC media statement)
• 20:10 Procalcitonin, CRP and antibiotic prescription for COPD exacerbation
• 24:30 Pneumococcal conjugate vaccine
• 30:00 Imposter syndrome
• 49:00 Vacation time and metabolic syndrome
• 57:00 Wrap-up and outro

Hotcakes

Imposter Syndrome

Reference: Mullangi S, Jagsi R. Imposter Syndrome: Treat the Cause, Not the Symptom. JAMA. 2019;322(5):403. doi:10.1001/jama.2019.9788 

In this opinion piece, Dr. Samyukta Mullangi and Dr. Reshma Jagsi (featured on Curbsiders episode #162, Gender & Sexual Harassment in Medicine) discuss the roots of ‘imposter syndrome’–the erroneous belief that one’s successes are a result of luck or chance, and not fully deserved. Imposter syndrome is commonly endorsed by women and minorities, and is a common affliction among those pursuing careers in academic medicine. 

Bottom line? 

The authors note that imposter syndrome is not simply a self-imposed insecurity that can be easily overcome by changing one’s way of thinking or by modifying professional behavior. Rather, it is related to other structural barriers that women and minorities in medicine face, such as lack of representation in leadership, inadequate resources dedicated to identifying and supporting diverse candidates, and insufficient follow-through from administrators in regards to building an equitable work environment.  

Dr. Manning’s Advice     

Remember that imposter syndrome is common. It’s not just you and is likely part of the bigger system. Be a better bystander by accepting differences and understand the societal pressures. And be your authentic self!

Vacation, all I ever wanted

Reference: Voelker R. Vacationing More Often May Reduce Metabolic Syndrome Risk. JAMA. August 2019. doi:10.1001/jama.2019.11134

Metabolic syndrome is a constellation of symptoms/conditions such as hypertension and obesity that can lead to elevated chronic disease risk (e.g. diabetes, heart disease, stroke). Although most employed adults have vacation days they can take each year, only half of this time is typically used. Recent research suggests that workers who use more of their allotted vacation days are less likely to meet criteria for metabolic syndrome, suggesting the benefits of taking vacation time may yield an overall positive effect on workers’ health and well being. 

See also: 

Hruska B, Pressman SD, Bendinskas K, Gump BB. Vacation frequency is associated with metabolic syndrome and symptoms. Psychology & Health. June 2019:1-15. Doi: 10.1080/08870446.2019.1628962

What’s the clinical question? Who is the patient population?

The researchers sought to explore the relationship between past-year use of vacation time, and symptoms of metabolic syndrome among adult workers. 

Study design

A total of 63 adult workers were recruited for the study, and took part in surveys and interviews to assess past-year use of vacation time. Participants were evaluated for metabolic syndrome through tests including measures of waist circumference, blood sugar, blood pressure and cholesterol. About half of all participants were employed in the fields of healthcare or education, and most were white women (mean age: 43). 

Bottom line? 

The study has some important limitations (retrospective design, limited study sample, generalizability of participant characteristics) but overall lends support to the notion that using one’s vacation time may reduce risk factors for metabolic syndrome. 

Pneumococcal Vaccine

Reference (Commentaries/JWatch): 

Zuger A. How Should We Use Conjugate Pneumococcal Vaccine in Immunocompetent Older Adults? NEJM Journal Watch. 2019.

Ampel N. Childhood Pneumococcal Conjugate Vaccination Benefits Adults. NEJM Journal Watch. 2019.

See the deliberation on YouTube: https://www.youtube.com/watch?v=wlb59e4bcSM

Background History 

In the United States, there are two FDA-approved vaccines for the prevention of pneumococcal infection:  the Pneumococcal conjugate vaccine (PCV13 or Prevnar 13®) and the Pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax23®). PCV13 is routinely administered to children, and since 2014 the CDC has recommended it be provided to healthy adults aged 65+ as well. Immunocompetent adults ages 65+ are also advised to receive PPSV23. 

Updates

However, the CDC’s Advisory Committee on Immunization Practices recently revisited the recommendations regarding administration of PCV13 to healthy older adults, and is now advising that clinicians (in consultation with their patients) determine its appropriateness on a case-by-case basis. The change in position appears to be driven by data suggesting PCV13, while safe and potentially helpful to select patients, is very expensive with a high ‘number needed to vaccinate’ annually in order to prevent one case of invasive pneumococcal disease (26,000 patients) or pneumonia (range: 2,600-14,000 patients). The recommendation for provision of PPSV23 to healthy adults ages 65+ has not changed. 

Childhood vaccination effects

Additionally, recent research suggests that vaccinating  children with PCV13 provides ancillary protection to adults, reducing the likelihood of contracting invasive pneumococcal disease (IPD) by 28% (further reduced to 40% when considering IPD caused by the strains PCV13 prevents). However, the study also found adults aged 65+ faced a 20% increase in risk of IPD infection from a pneumococcal virus strain not covered by PCV13. 

See also: 

• Weinberger DM, Warren JL, Dalby T, et al. Differences in the Impact of Pneumococcal Serotype Replacement in Individuals With and Without Underlying Medical Conditions. Clinical Infectious Diseases. 2019;69(1):100-106. doi:10.1093/cid/ciy875
• Vadlamudi NK, Chen A, Marra F. Impact of the 13-Valent Pneumococcal Conjugate Vaccine Among Adults: A Systematic Review and Meta-analysis. Clinical Infectious Diseases. 2019;69(1):34-49. doi:10.1093/cid/ciy872

Hot takes & honorable mentions 

• Centers for Disease Control and Prevention. Outbreak of illnesses associated with e-cigarette products. Published September 6, 2019. 
• ACP Hospitalist: Procalcitonin may not be reliable enough to withhold or mandate antibiotics in CAP
• Kamat IS, Ramachandran V, Eswaran H, Guffey D, Musher DM. Procalcitonin to distinguish viral from bacterial pneumonia: A systematic review and meta-analysis. Clinical Infectious Diseases. June 2019. doi:10.1093/cid/ciz545
• Butler CC, Gillespie D, White P, et al. C-Reactive Protein Testing to Guide Antibiotic Prescribing for COPD Exacerbations. New England Journal of Medicine. 2019;381(2):111-120. doi:10.1056/NEJMoa1803185

Vaping 

The number of e-cigarette associated lung illnesses continues rising, latest updates (after show recording) are 450 cases as of September 6, 2019 (CDC report). In August, the CDC released a Clinician Outreach and Communication Activity statement urging all providers to report cases of vaping related illness. Also, vaping pens have exploded! –see this NBC News story

Procalcitonin

A meta-analysis of 12 trials found procalcitonin had a sensitivity of 0.55 and specificity of 0.76 (Kamat, 2019) for distinguishing bacterial from viral community-acquired pneumonia. An ACP Hospitalist Weekly article warned procalcitonin may not be reliable enough to use for guiding treatment.

CRP

A recent randomized control trial involving outpatients with COPD presenting with an exacerbation found that using C-reactive protein (CRP) to guide antibiotic use resulted in 22% less patients getting antibiotics, without evidence of harms (Butler, 2019). The guidance given was a low CRP level (<20mg/L) was unlikely to benefit from antibiotics, a moderate level (20-40mg/L) may benefit particularly if purulent sputum is present, and high level (>40mg/L) is likely to benefit from antibiotics. 

Links*

• Reflections of a Grady Doctor, Dr. Kimberly Manning’s Blog
• To Kill a Mockingbird by Harper Lee, audiobook narrated by Sissy Spacek
• LeVar Burton Reads, a podcast
• Aziz Ansari Right Now (comedy special) and Master of None (TV show)
• Garfield Minus Garfield, an existential take on a classic comic
• Clue, the 1985 movie

Goals

Listeners will learn about relevant medical literature, with an emphasis on breaking news and recently published research. 

Learning objectives

After listening to this episode listeners will…

1. Learn about important journal articles and their salient points
2. Develop a framework to critically analyze journal articles in a practical way
3. Learn what medical news is being widely reported in the lay media and the underlying evidence in the literature
4. Review the current literature on the following subjects: (1) How ‘imposter syndrome’ is a structural issue impacting women and underrepresented minorities in medicine, (2) The effect of using paid vacation time on workers’ risk of metabolic syndrome, and (3) Recent changes to CDC recommendations regarding the administration of the pneumococcal conjugate vaccine (PCV13) to healthy adults. 
5. Recall the dangers of e-cigarettes
6. Evaluate the use of CRP for guiding antibiotic use in COPD exacerbation

Disclosures

Dr. Manning reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Citation:

Roberts SP, Chiu C, Okamoto E, Williams PN, Watto MF, Manning K. “Hotcakes: Imposter syndrome, the perks of vacation time, and a pneumonia vaccine update.” The Curbsiders Internal Medicine Podcast http://thecurbsiders.com/episode-list. August 26, 2019.