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

October 25, 2021 | By Matthew Watto, MD

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! 

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Credits

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

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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

• There is a low risk of progression from prediabetes to diabetes in older (Rooney, JAMA Int Med 2021)
• Simplify diabetes regimens with an SGLT2i or GLP1 agonist (Giugliano, Diabetes Care 2021)

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

• Approach to alopecia (#232 with Helena Pasieka)

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

• Practical considerations in seizures (#257 with Sara Dawit). 
• Quick typing of dementia (#268 with Josh Uy)
• Dementia Prevention (Livingston, Lancet 2020)

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

• Coffee consumption was inversely proportional to arrhythmias (Kim, JAMA Int Med 2021). But, be careful with alcohol (Larrson, 2014; Johansson, 2020)
• HTN goals and use of combo pills –see below for discussion
• ARBs are safer than ACEi (Chen, HTN 2021)
• Hyperaldosteronism is common. Testing has poor sensitivity (Hung, JCEM 2021). We should rethink how we test and manage suspected hyperaldo (Funder, Am J HTN 2021; Funder, HTN 2021).

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

• The chronic cough, a Thelma and Louise moment (#241 with Brad Hayward)
• PRN flonase is effective (Thongngarm, 2021)

GI

• Kiwis work for constipation. You don’t have to eat the skin! Chey, Am J Gastro 2021
• CRC screening age has dropped to 45 yo, AND lets the patient choose either stool testing or direct visualization (#283 with Michael Barry of the USPSTF). 
• Major changes to follow up recs for colon polyps (Gupta Am J Gastroenterol 2020)

Heme-Onc

• Tranexamic acid 1300mg TID for 5 days for HMB does not cause clots (#280 with Bethany Samuelson Bannow)

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). 

Links

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.