The Curbsiders podcast

#301 LIVE! Top Pearls 2021: A Rapid Fire Review of Systems

October 25, 2021 | By

Join us for this rapid fire review of systems featuring our top pearls and articles LIVE! from the TriService ACP conference. Matt and Paul serve up their favorite practice changing knowledge food on antibiotics, MRSA, hair loss, dementia, seizures, diabetes, medications for hypertension, foods for constipation, diverticulitis, colon cancer screening, colon polyps, chronic sinusitis, chronic cough, treatment of uterine bleeding, and more! 

No CME for this episode, but check out curbsiders.vcuhealth.org for past CME offerings!

Episodes | Subscribe | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com | Free CME!

Credits

  • Matthew Watto MD, FACP; Paul Williams MD, FACP   
  • Cover Art: Sawyer Watto
  • Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com

Sponsor: BetterHelp

Get 10% off your first month at betterhelp.com/curb.


Sponsor: ACP’s National Internal Medicine Day

Help the American College of Physicians celebrate National Internal Medicine Day on October 28th. Visit https://www.acponline.org/NIMD2021 to learn how you can show your internal medicine pride. Be sure to tag @ACPInternists and use the hashtag #NationalInternalMedicineDay.


CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. 


Show Segments

  • Intro, disclaimer
  • ID: Shorter is better; MRSA swabs; Antibiotics for diverticulitis
  • Endo: Prediabetes in older adults, 
  • MSK: Knee OA, orthopedic surgery
  • Derm: Alopecia
  • Neuro: Seizures, dementia quick typing
  • Cardio: Coffee and arrhythmias; Hypertension management, ACEi vs ARBs
  • Respiratory: Chronic cough and sinusitis
  • GI: CRC screening, foods for constipation
  • GU: treatment of uterine bleeding
  • Addiction Medicine: smoking cessation, buprenorphine
  • Outro

ID 

  • Shorter is Better (ACP guideline)
  • Recall the oral antibiotics that achieve high blood levels
  • Antibiotics for Diverticulitis
  • MRSA Swabs

Shorter is Better

Short course antibiotics (5 days or less) is adequate for many common infections like CAP, UTI, Cellulitis, Acute on Chronic Bronchitis (COPD), and even some cases of pyelonephritis (see figure based on the ACP guidance statement with input from #medtwitter) —Lee, Annals 2021

Made famous by @BradSpellberg on Twitter and his website: https://www.bradspellberg.com/shorter-is-better 

Bioavailable Oral Abx

@PaulSaxMD’s blog features this list of oral antibiotics with high oral bioavailability (thus achieving high blood levels) –source: Paul Sax’s ID Learning Unit

  • Fluoroquinolones (levofloxacin, ciprofloxacin, moxifloxacin)
  • Trimethoprim-sulfamethoxazole (TMP-SMX)
  • Metronidazole
  • Clindamycin
  • Doxycycline
  • Rifampin
  • Linezolid
  • Fluconazole

NOTE: The entire class of beta-lactam and beta-lactam-like antibiotics (penicillins and cephalosporins) are not on this list!

Antibiotics for Diverticulitis

  • Amox-clav affords similar diverticulitis related outcomes and might cause less harm compared to fluoroquinolones plus metronidazole (Gaber, Annals 2020)
  • It might be okay to forgo antibiotics for uncomplicated diverticulitis (AHRQ, 2019; AGA Guidelines 2015), but we’re still being wimps about it : ( 

MRSA Nasal Screen for Deescalation

  • MRSA nasal swabs (mostly PCR; some by culture) collected within 24 hours of admission (VA system; large retrospective cohort) had a negative predictive value of 96.5% for subsequent cultures drawn within 7 days. Thus, a negative MRSA swab is useful to rule out MRSA infection at other sites and deescalate anti-MRSA antibiotics (Mergenhagen, CID 2020). 
    • Nb. Do not apply this to critically ill patients! Use clinical judgment. 
    • Nb. PPV only 24.6% so do not use MRSA screen to escalate antibiotics. 
  • High Negative Predictive Value (96.5% overall)
    • Urine 99%
    • Intra-abdominal 98.6%
    • Blood Stream 96.5%
    • Respiratory 96.1%
    • Wound 93.1%

Endo


MSK

  • Physical therapy is superior to steroid injections for knee OA (Deyle, NEJM 2020)
  • Although they may be effective, many common orthopedic procedures lack strong evidence for benefit over nonoperative therapy. (Blom, BMJ 2021)

Derm

The Big 4 of Alopecia

The Big 3 for hair loss are alopecia areata (the bald spot), androgenic alopecia, and telogen effluvium (the bag of hair). We’d throw in traction alopecia as a 4th common cause. It’s caused by repetitive mechanical tension from pulling hair back, which can loosen hair from the follicles. Patients may develop bumps, redness, and tenderness. Certain professions e.g. ballerinas, gymnasts, and military personnel are prone. Prevention is the best treatment. Topical steroids and antibiotics may be used in some cases (Skin of Color Society). 

Topical minoxidil can be used for telogen effluvium, or androgenic alopecia (expert opinion). Counsel patients to use it nightly for 16 weeks to determine efficacy. A period of initial paradoxical shedding may occur. Indefinite use is required to maintain gains. 

Lab workup is minimal and can consist of TSH, ferritin, CMP, CBC, and maybe vitamin D.  Don’t send an ANA unless lupus is suspected (Telogen effluvium, Uptodate 2021).  


Neuro & Psych

Dementia Quick Typing

Does the person walk and talk slow? Or normal (“fast”)?

“Fast” and younger age = Alzheimer’s vs FTD. 

“Fast and older = Alzheimer’s

Slow with vascular risk factors = vascular

Slow with Parkinson features = PD vs Lewy Body dementia (Decide type by earliest symptoms)


Cardio

Hypertension Pearls

As a group, we suck at treating hypertension (Million Hearts). Most adults require two meds (Chobanian, 2008). Recent guidelines by ACP 2017, AHA 2017, ISH 2020, and KDIGO 2021 vary the targets. Here’s Watto’s current take: 

Lower is generally better (SPRINT 2015; Zhang, 2021), but for older adults with multiple comorbidities an SBP <150 mmHg is acceptable (ACP 2017). For most other adults an SBP <140 mmHg is acceptable (ACP, AHA, ISH), but <130 mmHg is ideal SBP <130 mmHg (AHA, ISH).

Use combination therapy

  • The ISH 2020 guidelines recommend ACEI/ARB plus CCB as first line, probably due to the ACCOMPLISH trial, which found significantly fewer cardiac events with ACEI/ARB plus CCB vs ACEI/ARB plus HCTZ despite similar BP control.
  • Use “quarter dose” or “half dose” (aka “standard dose”) of two agents instead of one agent at max dose (Bennet, 2017; Salam, 2019). 
  • Kaiser Permanente simplified for success with ACEI/HCTZ combo Jaffe 2013.

Pulm


GI


Heme-Onc


Addiction Medicine

  • Endless varenicline. It has to be safer than smoking (#252 with Steve Baldassarri)
  • X-waivers waived…kind of. Clinicians no longer need proof of buprenorphine training to obtain the x-waiver designation (SAMSHA 2021). 

Are included in the text above


Goal

Listeners will review tops pearls from Curbsiders episodes and practice-changing articles published in 2020-2021

Learning objectives

After listening to this episode listeners will…

  1. Recall top clinical pearls from Curbsiders podcast in 2020-2021
  2. Discuss top practice-changing articles and guidelines from 2020-2021

Disclosures

The Curbsiders report no relevant financial disclosures. 

Citation

Williams PN, Watto MF. “#301: LIVE! Top Pearls 2021: A Rapid Fire Review of Systems”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date, October 25, 2021.

Comments

  1. November 19, 2021, 3:23pm Aubrey Wheeler writes:

    Hi! Absolutely LOVE this podcast. I recommend it to all my residents/med students and I even dedicate lectures to tips I have l gleaned from you all. Question: what was the ACEI vs. ARB Retrospective article referenced by Paul? I feel like this could be practice changing for me and I'd love to bring it up to my residents, maybe for a journal club... but I'm having trouble finding it. Thanks! Aubrey

CME Partner

vcuhealth

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.

Contact Us

Got feedback? Suggest a Curbsiders topic. Recommend a guest. Tell us what you think.

Contact Us

We love hearing from you.

Notice

We and selected third parties use cookies or similar technologies for technical purposes and, with your consent, for other purposes as specified in the cookie policy. Denying consent may make related features unavailable.

Close this notice to consent.