#394 Recap, Top Pearls from ACP #IM2023

May 8, 2023 | By Matthew Watto, MD

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Don’t miss this rapid fire recap of our top pearls from ACP #IM2023 in San Diego including hypertension, hypogonadism, frailty, afib, sleep medicine, in-flight emergencies, nephroprotective meds, order of antibiotics for pneumonia in the hospital, genitourinary syndrome of menopause, pickle juice for leg cramps, bristol stool scale and hepatic encephalopathy, coronary calcium, tirzepatide, cystatin c,  functional dyspepsia, hair and nails, and more! Paul and Watto are joined by Drs. Justin Berk (@justinberk) and Chris Chiu (@cjchiu) of The Cribsiders Podcast.

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Show Segments

• Intro
• Recap, Top Pearls Part 1
• Recap, Top Pearls Part 2
• Outro

ACP #IM2023 Top Pearls

Hypogonadism (Bradley D. Anawalt, MD)

1. Hypogonadism: Don’t screen for it (Bhasin, 2018)! Decreased libido is the “most specific, non-specific symptom”. Make sure your lab is using a validated, “harmonized” site for testosterone testing. Early morning (preferably) fasting samples tend to be higher and have less variability (Brambilla, 2009, Bhasin, 2018). Obesity and increased waist circumference are addressable causes.
2. Klinefelter’s syndrome can present as infertility in men in their 20s and 30s. Nevertheless, extractable sperm may be present. A low testes volume can be detected using an orchiometer.
3. 2018 Endocrine Society guidelines recommend checking a hematocrit prior to and 3 to 6 months after initiation of testosterone therapy (Bhasin, 2018). PSA testing and sleep study are not necessary before treatment.

Frailty (Dave B. Reuben MD)

4. Frailty scores are useful for documentation, risk classification, and patient counseling. The speaker recommended 1) the FRAIL scale (Gleason, 2017) self report questionnaire, 2) the Clinical Frailty Score (Dalhousie University)  3) the Deficit Acculumation Index (Mitnitski, 2001). Movement practices and resistance training are recommended. Focus on “goal oriented” interventions. 

Hypertension (Shawna D. Nesbitt, MD, MS)

5. As a whole, we are not controlling patient’s blood pressure (Muntner, 2020). We need to be more aggressive, especially in patients with an ASCVD risk score greater than 10 percent (ACC/AHA 2017).
6. Optimize Life’s Essential Eight – Healthy eating, fitness, quitting nicotine, sleep, losing weight, cholesterol, diabetes, and blood pressure.
7. REGARDS study demonstrated dietary differences drove the higher incidence of hypertension in Black patients (Howard, 2018). 

Sleep Medicine (Kimberly A. Hardin, MD, MS)

8. Remember, sleep apnea is highly prevalent (Gottlieb, 2020) and a large percentage of patients with sleep apnea are undiagnosed (Young, 2009).
9. Avoid home sleep study if cardiopulmonary disease, on supplemental oxygen, neuromuscular disease, chronic opioids, or concerned about narcolepsy or another sleep disorder.
10. STOP-BANG was validated in older patients with overweight/obesity, but not young patients with low BMI (Chung, 2008) 
11. CPAP is first line for moderate to severe sleep apnea (AHI above 15), but surgical procedures including metabolic surgery can be considered a next step. 
12. Central sleep apnea is associated with afib (Sanchez, 2020), heart failure, and stroke (Rana AM [Updated 2023 Jan 23]).
13. Emergent central sleep apnea can arise in some patients started on treatment for OSA (Rana AM [Updated 2023 Jan 23]). 
14. PIVOT trial studied the use of a phrenic nerve stimulator for central sleep apnea (Costanzo, 2018). 
15. Cognitive behavioral therapy for insomnia (CBT-I) will be 1st line in forthcoming insomnia guidelines. Chris mentioned  https://www.sleepio.com/ and Veterans Affairs Insomnia Coach app. Watto mentioned Say Goodnight to Insomnia (book) and Online Course by Dr. Gregg Jacobs. 

Firearm Safety (ACP Press Briefing)

16. ACP has resources to help physicians talk to their patients about firearm safety including an online toolkit. 

Medicine and Incarceration (Newton E. Kendig, MD)

17. ACP has a policy paper from December 2022 on caring for patients who are incarcerated.
18. Medicaid 1115 Waiver will make some patients eligible for Medicaid before release from incarceration (Press Release from April 17, 2023)

Addiction Medicine (Keri Holmes‐Maybank, MD, MSCR)

19. Phenobarbital for inpatient alcohol withdrawal is finally being studied in an RCT, the PHENOMANAL trial (Filewod, 2021)

Aortic Stenosis (Rebecca T. Hahn, MD)

20. Lipoprotein(a) aka Lp(a) is associated with earlier valve calcification (Gudetti, 2020). 
21. The frequency of monitoring aortic stenosis should be proportional to the severity of the valve stenosis e.g. 3-5 years for mild, 1-2 years for moderate, and 6-12 months if severe (expert opinion). 

Perioperative Medicine (Avital O’Glasser MD)

22. Perioperative geriatrics is becoming a specialty. 
23. Think of patients with frailty as having low physiologic reserve (McDermid RC, doi.org/10.1093/med/9780199653461.003.0028, accessed 6 May 2023). 

Nephroprotection (Daniel W. Ross, MD)

24. He recommends aggressive blood pressure control, alkaline therapy, and SGLT2 inhibitors as key parts of nephroprotection (expert opinion). 
25. Aggressive blood pressure control, SBP under 120 mmHg, in CKD 4-5 decreased the probability of kidney failure in a meta-analysis (Ku, 2023) regardless of albuminuria, but not in CKD 3. 
26. Do not check the GFR after starting an SGLT2 inhibitor (expert opinion) because it will drop initially, but have a slower decline in the long term.
27. Alkaline therapy with a target serum bicarb “in the normal range” is recommended by the KDIGO guidelines for CKD (bullet 3.4.1). Fruits and vegetables are being studied as an alternative (Goraya, 2019).

In-Flight Emergencies (Jason D Napolitano, MD)

28. Wait at least 3 weeks to fly after myocardial infarction or pneumothorax, and 2 weeks after stroke. Do not fly if more than 35 weeks pregnant (Gendreau, 2002).
29. Air rage incidents page on Wikipedia. Physicians may be called to administer sedatives to the patient experiencing air rage. Dr. Napolitano cited one story of cabin depressurization from a passenger who broke a window and another incident of a death from asphyxiation in a restrained passenger. 

Updates in Hospital Medicine (Brad Sharpe MD)

30. Give beta-lactams prior to vancomycin to reduce early mortality in patients with suspected bloodstream infection (Amoah, 2022) even if suspicion of MRSA is high.
31. Hospitalist information cards improved the patient experience (Hasan Abid, 2022)

Genitourinary Syndrome of Menopause (Melissa Ann McNeil MD, MPH)

32. Symptoms may include Vaginal dryness, Painful sex, Urinary burning and dysuria, Urinary incontinence, Vaginal discharge, Vaginal itching, and burning, and Vaginal bleeding (Angelou, 2020)
33. Prognosis: Unlike vasomotor symptoms which tend to improve as women age these symptoms become worse and worse with time from menopause.
34. Therapy: Dr. McNeil recommended non-hormonal therapies like vaginal lubricants, regular vaginal stretching, or pelvic physical therapy for mild symptoms. Vaginal estrogen comes in various preparations (creams, inserts, rings) and is generally safe, and effective. 

Update in GI (Amy Oxentenko MD)

35. Bristol stool scale (BSS) incorporated into patient counseling about bowel movements (BM) improved outcomes in hepatic encephalopathy (Duong, 2022) when 2 to 3 BMs per day and BSS 3-4 were targeted.
36. PICCLES trial of pickle juice reduced muscle cramp severity, but not quality of life in patients with cirrhosis (Tapper, 2022). Be sure to use brined dill or kosher pickles, NOT bread and butter or sweet ones!

Hyponatremia (Helbert Rondon Berrios, MD)

37. U/P ratio (Furst, 2000) can help predict response to fluid restriction in SIADH with U/P = 1 (no response), >1 (try an additional therapy), and <1 (fluid restriction should work).
38. Urea provides a much higher salt (solute) load than salt tabs. You can get 500 mOsm from 30 gm of Urea (two sachets), which is equivalent to fifteen 1 gm Sodium Chloride tablets, or one 16-ounce steak (88 grams of protein).

Functional Dyspepsia (Xiao Jing Iris Wang, MD)

39. Provide a “positive diagnosis” of functional dyspepsia. Explain to patients that you expect their endoscopy to be negative and that a negative study does not mean they lack a problem.
40. Check out our Curbsiders episode #334  on Disorders of Gut Brain Interaction for an in-depth discussion with Dr. Wang.

Cystatin C (José E. Navarrete, MD)

41. Equations that include cystatin C-based eGFR are more precise and accurate than creatinine based eGFR alone  (Torres, 2022). The best equations combine these measurements.
42. Cystatin C may help reclassify the severity of CKD, especially if eGFR 45-60 range using creatinine. 
43. Cystatin C is useful when factors that affect Cr-based eGFR are present (advanced age, poor muscle mass, malnutrition, immobility).

Tirzepatide (Stephanie B. Mayer, MD)

44. Tirzepatide 5, 10, or 15 mg weekly provided a similar hemoglobin A1C reduction, but greater weight loss than semaglutide 1 mg weekly (Frías, 2021). **Update from Dr. Mayer: The cardiovascular outcomes trial “SURPASS-CVOT” is expected to complete in October 2024, NOT 2023.**
45. Patients with oral contraceptives should be wary upon tirzepatide initiation or dose change. **Update from Dr. Mayer: This effect was NOT seen with GLP1 agonists semaglutide, nor dulaglutide.**

Section 8.3 of tirzepatide package insert (FDA site): “Use of MOUNJARO may reduce the efficacy of oral hormonal contraceptives due to delayed gastric emptying. This delay is largest after the first dose and diminishes over time. Advise patients using oral hormonal contraceptives to switch to a non-oral contraceptive method, or add a barrier method of contraception for 4 weeks after initiation and for 4 weeks after each dose escalation with MOUNJARO [see Drug Interactions (7.2) and Clinical Pharmacology (12.2, 12.3)]”

Cardiovascular Risk Reduction (Lauren A. Weber, MD)

46. CAC scores may be higher in endurance athletes (Merghani, 2017; Aengevaeren, 2017) 

Hair and Nail Pearls (Helena Pasieka, MD)

47. Nail pearl: Benign features of longitudinal pigmented band include having multiple fingers involved, absent history of trauma, uniform border, even width, and even pigmentation. Concerning features include acute onset and involvement of a single digit with streaky borders.
48. Hair Pearl: Traction alopecia is initially reversible, but can cause irreversible hair loss if untreated (Akingbola, 2017).

Links

Links are embedded in the show notes above.

Goal

Listeners will develop recap the top pearls from ACP #IM2023 

Learning objectives

After listening to this episode listeners will…  

1. Feel generally warm and happy inside
2. Feel like they attended ACP #IM2023
3. Fall deeper in love with Dr. Paul Nelson Williams, #americasPCP

Disclosures

The Curbsiders and The Cribsiders report no relevant financial disclosures. 

Citation

Williams PN, Chiu CJ, Berk JL, Watto MF. “#394 Recap, Top Pearls from ACP #IM2023”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date May 8, 2023.