#270 SGIM 2021: The Highlight Reel

April 26, 2021 | By Sarah Phoebe Roberts

LGBTQ health, updates in primary care for patients of all ages, caring for the Muslim patient, periop pearls, MRSA in your nose, and more!

Summary

It’s SGIM 2021, #SGIM21! LGBTQ health, updates in primary care for patients of all ages, caring for the Muslim patient, periop pearls, MRSA in your nose, and more!

It’s the most wonderful time of the year for internists: SGIM and ACP, all in one month!  We’re here to help you make the most out of these action-packed virtual events, starting with our SGIM 2021 conference highlights. We hope you enjoy this grab-bag of clinical pearls, from LGBTQ healthcare to periop medicine to primary care, reproductive health, and beyond. Stay tuned for our upcoming ACP IMM2021 recaps for even more knowledge food!

Credits

• Written, Produced, and Hosted by: Sarah Phoebe Roberts MPH; Becca Raymond-Kolker, Paul Williams MD, FACP; Chris Chiu MD, FACP, FAAP; Matthew Watto MD FACP 
• Show Notes by: Sarah Phoebe Roberts MPH
• Cover Art and Infographic: Sarah Phoebe Roberts MPH
• Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com

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Show Segments

Top Pearls on:

• LGBTQ health
• Gynecological health 
• Reproductive medicine 
• Primary Care 
• Hospital Medicine 
• Perioperative Medicine 
• Caring for the Muslim patient 
• Young adult medicine pearls (including COVID19; and Down Syndrome)
• Reflections on SGIM 2021 and Outro

SGIM 2021 Highlight Reel: Show Notes

LGBTQ Health

Session attended: LGBTQ Bootcamp for Clinician Educators – Educating Trainees About the Clinical and Social Aspects of Comprehensive Care for Sexual and Gender Minorities

Presenters: Chris Terndrup MD, Carl Streed Jr. MD MPH, Jenny Siegel MD

Top Pearls:

• GIM clinicians/trainees are well-positioned to address existing healthcare disparities among LGBTQ patients. Important to expand and enhance training in LGBTQ health across medical education.
• LGBTQ patients bring prior medical trauma w/ them, and focused education on trauma-informed approaches is important:
  • Ex: if pt is wearing a chest binder, instead of saying “you need to remove that”, explain the reasoning and give patient options/alternatives e.g. “I think for us to do a safe exam we should probably listen to the lungs without the binder on, how do you feel about that?” 
  • Binding
    • Chest binding, also known as binding, is a technique used to create the appearance of a flatter chest. Often used by affirmed males or transmasculine non-binary folks. 
    • Model looking things up with your learners!
• Avoid misgendering 
  • What is misgendering?   The experience of being labeled by others a gender other than one that a person identifies with. It is a microaggression that contributes to negative healthcare experiences. 
    • Be aware not just of verbal misgendering, but paper-based and electronic misgendering. Correct health records and update with correct name/pronouns as needed.
    • Ask: What name do you use/what do you like to be called? What pronouns do you use?
• Be aware of confirmation bias or ‘tunnel vision’ when thinking about gender-affirming care; avoid making assumptions about a patient’s health based on their status as a gender or sexual minority. Bottom line: don’t be reductive about patients!

Sexual & Reproductive Health, Women’s Health 

Session attended: Reproductive Healthcare

Advocating for Equity: Removing Barriers to Reproductive Healthcare in 2021

Presenters: Sarah Merriam MD, Eleanor Bimla Schwarz MD MS, Emmanuelle Benkoski Yecies MD, Deborah Kwolek MD, Pelin Batur MD, Deirdre A. Quinn PhD, MS

Top Pearls

• For pts using OCPs, prescribe a year’s worth if legal in your state 
• For LARCs, use telehealth for pre-insertion paperwork/counseling so pt only needs to come into the office once for the procedure 
• Prioritize same-day contraceptive initiation, don’t delay starting a method 
• Internists can play an important role in prescribing medication abortion for pregnancies up to 77 days (~11 weeks) [Note: the presenter described prescribing/managing medication abortion up to 11 weeks, but this may be limited to 10 weeks depending on your location]. 
  • In the majority of states, you can manage medication abortion via telehealth. There are 19 states, however, that require the clinician to be in the room with the patient when they take the pills. 

Session attended: Clinical Update in Women’s Health

Presenters: Judith M.E. Walsh MD, Brigid M. Dolan MD, Sarah Merriam MD, Christine Prifti MD

Top Pearls

• Consider a history of migraine with aura as part of overall CV risk in women.
  • Association of Migraine With Aura and Other Risk Factors With Incident Cardiovascular Disease in Women Kurth T et al. JAMA 2020
  • Examined cohort of 27,858 women (taken from the Women’s Health Study)
  • Looked at exposure of self-reported migraine with aura compared with migraine without aura or no migraine at baseline
  • Women with migraine with aura had a higher incidence rate of major CVD events
    • More strongly associated with CVD than obesity or unfavorable lipids
    • Similar association as elevated systolic blood pressure
• Severe vasomotor symptoms of menopause may be associated with elevated cardiovascular risk in women, and this information may help aid in decisions about cardiovascular risk reduction. 
  • Vasomotor menopausal symptoms and risk of cardiovascular disease: a pooled analysis of six prospective studies Zhu DS et al.  American Journal of Obstetrics & Gynecology 2020
  • Severity rather than frequency of hot flashes and night sweats were associated with higher incidence of cardiovascular disease
  • Early-onset and late-onset of symptoms also associated with higher incidence
• Screen and treat women for symptoms of the genitourinary symptoms of menopause
  • The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society Menopause: The Journal of the North American Menopause Society 2020
  • Because women may not spontaneously endorse symptoms of the genitourinary syndrome of menopause (GSM) and related sexual concerns, clinicians should inquire about symptoms in all peri- and post-menopausal women
  • First-line therapies for non-severe symptoms are lubricants and moisturizers
  • If insufficient, consider vaginal estrogen or DHEA
    • Systemic risks of topical estrogen are low
  • Systemic estrogen can be considered if vasomotor sx are also present
    • If there is a history of breast or endometrial treatment, consider consultation with the patient’s oncologist before beginning hormone-based therapy
• The absolute risk of atypical femoral fracture in bisphosphonate therapy is low compared to reduction in hip fractures
  • Atypical Femur Fracture Risk versus Fragility Fracture Prevention with Bisphosphonates Black DM et al. NEJM 2020

• Study on relationship between hair dye and cancer risk is mostly reassuring about the use of hair dye and cancer risk. The small association with certain cancers warrants further evaluation. Occupational exposure to hair dye is probably carcinogenic.
  • Personal use of permanent hair dyes and cancer risk and  mortality in US women: prospective cohort study Zhang Y et al.  BMJ 2020
• A 2020 NEJM study indicates the HPV vaccine reduces the risk of invasive cervical cancer (in addition to preventing high-grade dysplasia)
  • Adjusted IRR shows 88% reduction in invasive cervical cancer if pt vaccinated before age 17
  • Takeaway: effect size of vax is stronger in younger patients, but 50% of pts in adult practice have not had vax series completed, so important to follow up and complete the series. 
• Gabapentin doesn’t work for chronic pelvic pain 

General Primary Care Updates 

Session attended: Caring for Muslim Patients

Presenter: Umna Ashfaq, MD

Top Pearls: 

• There is a great deal of diversity in the cultural backgrounds of Muslims and in the practice of Islam. No universal set of recommendations but important points to be mindful of in order to provide culturally appropriate care.
  • Broaching STI/sexual and reproductive health conversations for patients: she used the key phrase “I ask this of all my patients/I do this (e.g. conducting STI tests) for all my patients” 
• For Muslim patients who fast during Ramadan: 
  • Ramadan is a holy month in Islam during which observant Muslims will fast from sunrise to sunset. This year Ramadan is April 12-May 12, 2021. 
  • Muslims who are elderly, sick, pregnant, nursing, or menstruating are not required to fast, but most patients with chronic conditions still will:
    • Per 2010 CREED study, ~94% of patients with type 2 diabetes fasted for at least 15 days, and ~64% fasted every day.
  • Important to counsel fasting patients on dietary and medication adjustments. For patients with diabetes, consult the evidence-based recommendations put together by the International Diabetes Federation in collaboration with the Diabetes and Ramadan International Alliance. 
    • Patients with diabetes should be reassured that blood glucose monitoring and insulin injections do NOT nullify the fast. 
  • Pts on BP medication, anticoagulants, diuretics and thyroid supplements should also have their doses reviewed and adjusted if needed
• For Muslim patients who complete the Hajj: 
  • Hajj is the religious practice of making a pilgrimage to the holy city of Mecca, Saudi Arabia. In 2021, the Hajj will take place from July 17 to July 22nd. 
  • Pts should be prepared for extensive physical activity (lots of walking) required during Hajj 
  • Counsel patients on:
    • Proper foot care, including a daily foot inspection
    • Hydration and sun protection 
    • Medications (ensure pt has ample supply, recommend bringing loperamide, consider abx rx in case of severe traveler’s diarrhea) + identification bracelets for chronic medical conditions
    • Nutrition- pts should not skip meals and should check blood sugar and eat carbs prior to physical exertion
    • Facemasks + handwashing to reduce risk of communicable disease
    • Certain vaccinations are required by Saudi government; consider adding Tdap if out of date, pneumonia vax for pts 65+ with comorbidities.   
  • For female pts of reproductive age, start OCP 1 week before Hajj and continue until 1 week later; this is important as menstruating women are not supposed to perform Tawaf, which is one of the principal rites of Hajj.  
  • Men will typically shave their heads during Hajj, which carries the risk of blood-borne illness–rec is to go to licensed barbers only.  
  • Patients should postpone Hajj if:
    • Recent MI or high risk for MI
    • HF patients at risk for exacerbation or arrhythmia
    • COPD/asthma patients at risk for exacerbation
    • Advanced kidney disease
    • Uncontrolled HTN
    • Uncontrolled diabetes
    • Immunodeficient patient/pt with active cancer
    • Limited mobility/high fall risk 

Session attended: Clinical Update in Primary Care

Presenters: Jeremy Smith MD FACP, Jason T. Alexander MD, Simran Singh MD, David Williams MD

Top Pearls: 

• A team of SGIM physicians reviewed the most impactful IM/primary care relevant articles from the past two years. Here are some highlights! 
• Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction
  • SLT2i (DAPA-HF)
  • 25% reduction in primary outcome (worsening symptoms or CHF death).
    • NNT 21
  • All cause mortality reduced 17% regardless of DM
• Apixaban for Cancer-associated VTE (new VTE with active cancer other than brain/skin)
  • HR 0.63 for apixaban for recurrence (NON-INFERIOR)
  • No difference in safety or mortality
  • Prior Curbsiders episode with Dr Michael Strife on VTE
• Compressions stockings for prevention of recurrent cellulitis
  • Compression stockings are good! (Webb NEJM 2020; 383:630-639
  • DOI: 10.1056/NEJMoa1917197)
  • Study was stopped early because of the superior efficacy/benefit to patients in the compression socks condition 
• Early Rhythm-Control Therapy in Patients with Atrial Fibrillation
  • EAST-AF trial: Early rhythm control (antiarrhythmic or ablation) resulted in a significant reduction in cardiac events (stroke, death).
    • No difference in safety.
    • Trial stopped early for benefit .
    • Early referral to cardiology for rhythm control is reasonable.
  • See what the CardioNerds Journal Club had to say!
• Controlled Trial of Budesonide-Formoterol as Needed for Mild Asthma
  • Combined LABA/ICS vs. SABA vs ICS + SABA.
  • Excluded heavy smokers.
  • Outcome: urgent care, steroids, heavy SABA use
  • LABA/ICS = ICS + SABA > SABA
    • Reduced severe exacerbations compared to both.
    • Lower steroid use in LABA/ICS.
• Time-Restricted Eating/Intermittent Fasting vs Consistent Meal Timing (TREAT Trial in JAMA IM)
  • 116 pts randomized to either fast 16:8 hours or eat 3 meals + snacks 
  • TRE no more effective for weight loss than consistent meal timing.
  • 1% weight loss in both groups.
• CRP to guide ABX-Rx for COPD exacerbations (2019)
  • Anthonisen criteria (DOB, sputum volume, sputum purulence)
  • CRP <20 less beneficial; >40 more beneficial
  • Patient-reported ABX use RR 33%, NNT 4
  • POC test
• Colchicine in CAD (LoDoCo2 Trial)
  • In patients with stable CAD on evidence-based therapies, colchicine may reduce CV events; but further research is needed as to why non-CV-related deaths were elevated
  • 5K participants, CAD on CTA or angiography or CAC > 400
  • Followed for 28 months
  • HR 0.69 in Composite outcomes (NNT 36)
  • No change in all-cause mortality (trend towards non-colchicine). Non-cardiovascular death 0.99-2.31 favoring no colchicine.

Hospital Medicine 

Session Attended: Clinical Update in Hospital Medicine

Presenters: Bradley Allen Sharpe MD, Keri Holmes-Maybank MD

Top Pearls:

Microbiology of Aspiration Pneumonia

• Aspiration Risk Factors, Microbiology, and Empiric Antibiotics for Patients Hospitalized With Community-Acquired Pneumonia, Marin-Corral et al. Chest 2021 
• Multicenter, point-prevalence study of patients admitted with CAP
• Anaerobes are rare, GNRs and CAP more common
• Takeaway Point: Consistent with ATS/IDSA guidelines recs against empiric anaerobic treatment.

Restrictive vs Liberal Transfusion in MI 

• Effect of a Restrictive vs Liberal Blood Transfusion Strategy on Major Cardiovascular Events Among Patients With Acute Myocardial Infarction and Anemia: The REALITY Randomized Clinical Trial, Ducrocq JAMA 2021 
• Restrictive (Hgb < 8 g/dL) non-inferior to liberal transfusion strategy for MACE
• No difference in MACE at 30 days.

Nasal Screen for MRSA

• Takeaway Point: When checked within 7 days, great NPV; thus, can be useful to rule out MRSA and avoid anti-MRSA abx if swab negative.
• Determining the Utility of Methicillin-Resistant Staphylococcus aureus Nares Screening in Antimicrobial Stewardship, Mergenhagen et al Clinical Infectious Disease Sept 2020 
  • High Negative Predictive Value (96.5% overall)
    • Blood Stream 96.5%
    • Intra-abdominal 98.6%
    • Respiratory 96.1%
    • Wound 93.1%
    • Urine 99%
• Poor sensitivity 67.4%, PPV 24.6%

Perioperative Medicine 

Session Attended: Clinical Update in Perioperative Medicine

Presenters: Michele Fang MD, Priyanka Bhugra MD, Mehrshid Kiazand MD, Paul B. Cornia MD, Kay Johnson MD

Top Pearls:

Gabapentinoids for Post-op Pain

• Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain: A Systematic Review and Meta-analysis, Verret Anesthesiology 2020 
• Systematic review and meta-analysis: Gabapentin or pregabalin for post-op acute pain
• No effect on acute (up to 72 hrs), subacute (up to 12 weeks), chronic (>3 mo) pain
• Increase visual disturbances and dizziness
• DECREASE post-op N/V (PONV)!

Periop Cannabis Consensus Recommendations

• Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process, Ladha Br J Anesth 2021 
• Modified Delphi process
• Consider weaning or stopping use >7 days prior to OR. DO NOT stop <1 day prior to OR
• Persons with daily use of cannabinoids may require additional PONV prophylaxis AND/OR higher doses of anesthesia to receive desired effect
• Consider continuing cannabinoid oils or edibles post-op (based on local law)

Cirrhosis

• Risk Prediction Models for Post-Operative Mortality in Patients With Cirrhosis, Mahmud Hepatology 2021 
• VOCAL-Penn Cirrhosis Surgical Risk Score tool: Vocalpennscore.com 
• Presenter recommends using this to complement the standard periop risk assessment

Young Adult Health

Session attended: Clinical Update in Young Adult Health

Presenters: Christopher Hanks MD, Sara Mixter MD MPH, Lee Shearer MD, Jeri Lynn Lantz MD, Mariecel Pilapil MD

Adults with Down Syndrome

• Medical Care of Adults With Down Syndrome: A Clinical Guideline, Tsou et al JAMA 
• First time there has been Evidence-Based Guidelines (Evidence Graded)
  • Many recs are the same as general population like ASCVD risk
  • Different from General Population
    • Diabetes screening asymptomatic at 30yo w/Down syndrome (vs 40yo per USPSTF) and q3yrs
    • Diabetes screening with obesity at 21yo and q2-3yrs
  • Caution dx Alzheimer dementia at <40yo. Consider other DDx first. Assess annually for Alzheimer’s after 40yo.
  • NEW
    • Mental Health disorder being considered? Refer to a clinician experienced with Down Syndrome. Dx should be made following DSM-5 (or DM-ID-2)
    • CHD needs to be referred to Cardiology for periodic eval
    • Hypothyroidism screening age 21 and q1-2 years
    • C-Spine X-rays SHOULD NOT be used for screening for atlantoaxial instability

COVID-19 and MIS-A

• Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection — United Kingdom and United States, March–August 2020  
• >21yo, severe illness requiring hospitalization, evidence of current/previous SARS-CoV-2 infection, absence of pulmonary illness, elevated inflammatory markers, extra-pulmonary organ dysfunction
• MMWR case series data from 27 pts, 21 are racial/ethnic minorities, age range 20-50 y/o Treatment extrapolated from MIS-C, no consensus
  • Kawasaki Cocktail: IVIG, high-dose ASA, +/- Steroids, 
  • Active infection tx: Anticoag, Remdesivir, Convalescent plasma
  • Anakinra: IL-1 inhibitors

Goal

Listeners will learn about a variety of topics in primary care and hospital medicine that were presented at the Society of General Internal Medicine 2021 (#SGIM21) virtual conference.

Learning objectives

After listening to this episode listeners will…  

1. Become familiar with the latest research in gynecologic care, reproductive health, primary care, young adult, hospital, perioperative and geriatric medicine
2. Update themselves on new or modified guidelines related to the treatment of acute and chronic conditions common in primary care and hospital settings  
3. Reflect on the role of the internist in providing equitable healthcare access to vulnerable or underserved patient populations 

Disclosures

The Curbsiders report no relevant financial disclosures. 

Citation

Roberts SP, Williams PN, Chiu CJ, Berk J, Raymond-Kolker B, Watto MF. “#270 SGIM 2021: The Highlight Reel”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date April 26, 2021.