#185 Hotcakes: CAP, Asthma & Red Meat

November 27, 2019 | By Sarah Phoebe Roberts

Spookycakes with Cranberry Sauce, Thanksgiv-o-ween 2019

Summary

“Guidelines” galore! From Community-Acquired Pneumonia to asthma to…red meat? While you may be listening to this around Thanksgiving, we actually recorded on October 30th‒the best and spookiest time of the year. To really set the mood I wanted to include some terrible skeleton puns, but the ones I found weren’t humerus. What we do have for you are some tasty knowledge treats, courtesy of our ghosts‒oops, I mean our HOSTS‒Chris, Matt, Stuart and Paul. Join us as we review the most terrifyingly relevant research findings and creepiest clinical pearls!

Today also marks the debut of our newest Hotcakes team member, the frighteningly talented Dr. Rahul Ganatra. Rahul will now be our resident statistician/study design expert, and will use his research skulls‒no wait, SKILLS‒to provide even more insight into the practice-changing findings we love to highlight for you.

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Credits 

Written and Produced by: Sarah Phoebe Roberts MPH, Christopher Chiu MD
Hosts: Matthew Watto MD, Stuart Brigham MD, Paul Williams MD, and Christopher Chiu MD
Statistics Expert: Rahul Ganatra MD
Editors: Christopher Chiu MD (audio/text), Emi Okamoto MD (text)
Cover-Art: Sarah Phoebe Roberts MPH
Music: Stuart Brigham MD

Time stamps

• 00:00 Introduction/Disclaimer
• 03:18 Getting to know Dr. Rahul Gantra
• 05:35 Community-Acquired Pneumonia Guidelines
• 15:13 Sarah explains Hotcakes ratings
• 16:45 A new Asthma Strategy
• 17:26 Chris forgets what LABA stands for
• 27:37 Stuart makes a joke
• 29:00 A lot of meat talk
• 37:22 Rahul’s Napkin Calculations
• 51:40 Honorable Mentions
• 52:42 Take-away Points & Outtro

Meet Rahul:

Rahul Ganatra is a Medical Attending and Director of Continuing Medical Education for the Medical Service at the VA Boston Healthcare System.  He fell in love with clinical epidemiology and public health while taking night classes for his MPH during medical school. and went on to become an applied epidemiology fellow at the Centers for Disease Control and Prevention.  He completed his residency and chief residency in internal medicine at Beth Israel Deaconess Medical Center, where he worked as a hospitalist for two years before coming to the VA, where he is currently the faculty mentor for the resident journal club.  In addition to critical appraisal, he loves cool animal facts and subjecting friends and colleagues to tirades about animal physiology.

Hotcakes

ACP Hospitalist Weekly. ATS/IDSA 2019 Community-Acquired Pneumonia Clinical Practice Guideline (update). Oct 09, 2019. (ACP Hospitalist Summary)

1. See also: Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67. doi:10.1164/rccm.201908-1581ST

What’s the clinical question? The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) have released updated guidelines for the diagnosis and treatment of Community Acquired Pneumonia (CAP). 

Bottom line? Several notable changes have been made to the guidelines, which were last updated in 2007. Among them are recommendations on collecting sputum and blood cultures from inpatients, whether procalcitonin should inform treatment, adjuvant corticosteroids,  beta-lactam/macrolide antibiotic therapy, and follow-up chest imaging. 

Guideline takeaways: 

1. Do not routinely add anaerobic coverage for “aspiration pneumonia”
2. HCAP is dead. Assess risk factors for MRSA, Pseudomonas. If severe CAP give extended spectrum coverage, send cultures and de-escalate in 48 hours.
3. Steroids should only be used if refractory shock
4. Be liberal with oseltamivir
5. Treat for no less than 5 days
6. Avoid routine follow up CXRs. Screen for lung cancer in patients who meet criteria.

Global Initiative for Asthma (GINA)

What’s the deal? First major update in 30 years: (1) ICS-LABA can be prescribed for both maintenance and rescue inhaler. (2) ICS-LABA can also be started even in those with mild asthma vs previous recommendations for ICS along and “step up” to ICS-LABA. (3) Albuterol mono-therapy may be avoided entirely but GINA doesn’t specifically advise against use or as add-on therapy. (4) Budesonide-fomoterol (Symbicort in the US) or beclomethasone-formoterol (Fostair outside US).

Why the change? In Europe, patients have long been using ICS-LABA as rescue but albuterol has been a mainstay in the US. The SMART strategy (meta-analysis of 16 RCTs) in JAMA 2018 showed pts showed fewer asthma exacerbations, hospitalizations, ED visits with ICS-LABA vs SABA. The ICS-LABA had 23% fewer exacerbations than those with higher dose ICS-LABA as maintenance. In NEJM 2018, a pair of trials SYGMA 1 and SYGMA 2 (Symbicort Given as needed in Mild Asthma). 

SYGMA 1 showed prn budesonide-formoterol as superior to prn terbutaline and similar to maintenance budesonide but with lower cumulative ICS dose. SYGMA 2 showed that budesonide-formoterol prn was noninferior to BID budesonide for rate of severe asthma exacerbations but inferior to symptom control (but 1/4th the amount of inhaled glucocorticoid exposure!). NEJM Editorial by Dr. Lazarus indicates that a switch could have $1 billion/year in drug savings in the US alone. [Note: revisit Curbsiders episode #102 to learn more about SYGMA 2!]

Critique? From practical standpoint, will need to work with insurances as they may not approve “early” use per previously established guidelines. Currently, no FDA indication for prn use so would technically be “off-label”.

Bottom line? GINA “strategy” is here to stay. It will take some time for providers, insurers and patients (at least in the US) to get on-board. Big change! HOTCAKES!

Zeraatkar D, Han MA, Guyatt GH, et al. Red and Processed Meat Consumption and Risk for All-Cause Mortality and Cardiometabolic Outcomes: A Systematic Review and Meta-analysis of Cohort Studies. Ann Intern Med. October 2019. doi: 10.7326/M19-0655

1. See also: Johnston BC, Zeraatkar D, Han MA, et al. Unprocessed Red Meat and Processed Meat Consumption: Dietary Guideline Recommendations From the Nutritional Recommendations (NutriRECS) Consortium. Ann Intern Med. October 2019. doi:10.7326/M19-1621

Today on the menu: How bad is red meat for you, really? 

Study design: Systematic review of 55 large cohort studies (representing over 4 million individuals) assessing the relationship between red meat intake and mortality, cardiovascular outcomes, and T2 diabetes.

Bottom line? Low-certainty evidence suggests that reducing red meat intake is associated with a very small reduction in mortality and cardiometabolic outcomes. Many confounders to consider. 

Bonus: Rahul’s back of the napkin calculations…

Hot takes & honorable mentions 

1. Comparing Direct Challenge to Penicillin Skin Testing for the Outpatient Evaluation of Penicillin Allergy – J Aller Clin Imm 2019 (JWatch)
2. Comparative Accuracy of Focused Cardiac Ultrasonography and Clinical Examination for Left Ventricular Dysfunction and Valvular Heart Disease – Annals IM 2019 (JWatch)
3. Blood Culture Results Before and After Antimicrobial Administration in Patients With Severe Manifestations of Sepsis – Annals 2019
4. Modifiable risk factors, cardiovascular disease, and mortality in 155722 individuals from 21 high-income, middle-income, and low-income countries (PURE) – Lancet Sept 2019 
5. Association Between Soft Drink Consumption and Mortality in 10 European Countries – JAMA IM 2019
6. Bedside Rounds -Historical Framework of Medical Epistemologies
7. Dr. Kimberly Manning’s advice on how to give learner feedback
8. Dr. Tony Breu’s Tweetorial on why influenza peaks in the winter
9. Dr. Tony Breu’s Perspective – Why Is a Cow? Curiosity, Tweetoral, and the Return to Why
10. Statins for primary prevention of CV disease – BMJ Oct 2019
11. NICE Adult Hypertension Guidelines – BMJ Oct 2019
12. Triglyceride lowering associated with lower major vascular events – Circ Sept 2019
13. Christopher Chiu’s Tweetorial on Why HCAP is Dead

Goals and Learning Objectives

Goals: 

Listeners will learn about relevant medical literature, with 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)American Thoracic Society and Infectious Diseases Society of America updated guidelines for the diagnosis and treatment of Community Acquired Pneumonia; (2) updated asthma treatment strategy and recommendations from the Global Initiative for Asthma; (3) the association between red meat intake and mortality and cardiometabolic outcomes. 

Disclosures: 

The Curbsiders report no relevant financial disclosures.

Please feel free to reproduce, share and/or edit these wonderful show notes and figures! Just give us credit! Love, The Curbsiders Team.