#464 Recap Extravaganza: Dental Pain, Cardiac Amyloidosis, Diabetes & CGMs, Hyperparathyroidism, Neck Pain, Endometriosis, Rhinitis, and more!

December 23, 2024 | By Matthew Watto, MD

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Transcript available via YouTube

Join us as Paul and Watto reflect on the past year, discussing some favorite insights gained covering a range of topics, including dental pain management, cardiac amyloidosis, the impact of continuous glucose monitoring on diabetes care, the complexities of diagnosing primary hyperparathyroidism, hepatitis B screening and vaccination, GLP-1 agonists, travel medicine, endometriosis, rhinitis, and recurrent UTIs.  Plus, we feature listener voicemails sharing their favorite episodes and why they love the Curbsiders!

No CME for this episode, but claim CME for past shows at curbsiders.vcuhealth.org!

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Show Segments

• 00:00 Introduction and Year-End Reflections
• 02:59 Picks of the Year
• 05:53 Dental Pain and Oral Care Insights
• 10:25 Cardiac Amyloidosis
• 14:33 Listener mail- diabetes
• 16:33 Neck Pain
• 19:08 Continuous Glucose Monitoring in Diabetes
• 23:57 Hyperparathyroidism
• 30:48  Hepatitis B 
• 34:01 Listener mail- obesity
• 36:14 Travel Medicine: Malaria, Diarrhea, and Vaccination
• 40:38 Endometriosis
• 46:08 Rhinitis and Environmental Allergies
• 49.24  Recurrent UTIs
• 55:08 Reflections on Nine Years of Curbsiders

Part 1: Picks of the year

Movie, TV, books, podcasts, social media channels, etc. 

1. Paul – The Vandalist (album) by Noga Erez 
2. Watto – Soccer (watch, coach, play)

Part 2: Top Pearls

#423 Dental Pain, Caries, Gingivitis, and Oral Care Tips & Tactics for Primary Care With Dr Lisa Simon

Gingivitis is inflammation of the gums, which can range from asymptomatic to uncomfortable but doesn’t cause deep tooth pain.  Since the gums do not attach the teeth to the bone, gingivitis will not cause teeth to loosen or fall out. However, gingivitis can be a precursor to worsening dental disease like periodontitis. 

Periodontitis is deeper inflammation around the base of the tooth, which can cause bone loss, tooth loosening, and space can develop, predisposing to abscess.  This deeper damage is what causes severe tooth pain as the nerve root gets involved (Stephens 2018)

Persistent dental pain means you are probably headed for a root canal or extraction.

• Short-term analgesia typically 800mg ibuprofen three times daily with acetaminophen 1g 3-4x daily is appropriate. 
• Typically patients do not need opioids to manage dental pain. 
• Small amounts of topical anesthetics like benzocaine can be relieving.
• Dr Simon recommends PCPs feel comfortable prescribing antibiotics for palliative/pain relief while waiting to see a dentist for definitive treatment.  She finds a course of antibiotics- while not definitive/does not get source control of the infection, does reduce inflammation and can give 4-6 weeks of pain relief.  Penicillin VK and amoxicillin are first line.  Clindamycin should be reserved for penicillin-allergic patients due to clostridium difficile risk. (Lockhart 2019)

Dental societies recommend against antibiotics for dental pain, but Dr Simons highlights that these guidelines are aimed at dentists who are in a position to provide definitive solutions (ADA 2019).  However, as a primary care provider, antibiotics are an appropriate form of harm reduction while the patient finds a dentist. 

#427 Kittleson Rules Amyloidosis

Cardiac amyloidosis is more common than you think; don’t assume increased LV thickness on the echo is “hypertrophy”.  About 1 out of 8 patients admitted with acute diastolic heart failure in case series have cardiac amyloidosis (González-Lopéz, 2015). Other clues include bilateral carpal tunnel syndrome, biceps tendon rupture, polyneuropathy, and autonomic dysfunction. 

The first step is to ensure the patient does not have AL amyloidosis by checking serum/urine IFE and serum free light chains. Patients with AL amyloidosis need urgent hematology referral for chemotherapy. If AL amyloid testing is negative, then proceed to technetium pyrophosphate scintigraphy. When the heart shines brighter than the bones, it is diagnostic for cardiac amyloidosis even without a myocardial or fat pad biopsy! Hereditary cardiac amyloidosis can be wild-type (associated with aging) or hereditary. Tafamidis is an expensive targeted therapy that improves survival in ATTR-CM.

Listener Voicemail #1

Dr. AJ “Big Daddy Shaddy,” a family medicine physician from Michigan, highlights the episode with Dr. Colburn on CGMs, in which we learned that avoiding nocturnal hypoglycemia can improve the A1C.

#435 Neck Pain with Dr. Anthony Mikula

Mechanical Neck Pain is quite common and presents without neurologic deficit.  It is often difficult to discern what the specific pain generator is, but it is usually due to muscular or ligamentous factors related to posture, poor ergonomics, or chronic muscle fatigue (Rao, 2002).  Radiculopathy from neuroforaminal stenosis is typically unilateral, so if the pain radiates to both shoulders, this may suggest myofascial pain.  Patients with red flags or high-risk features such as history of malignancy or injection drug use may warrant more aggressive work-up and imaging, as would patients with frank neurologic deficits.

Cervical Radiculopathy occurs when there is impingement or compression of a cervical nerve root as it exits the spine.  This can be due to disc herniation or simply from the degenerative changes of aging.  Patients may report alleviation of their pain with elevation of the arm above the head, a maneuver that may relieve some of the pressure on the nerve root (Childress and Becker, 2016).  Radicular nerve pain typically radiates down the arm in a pattern dictated by the affected nerve. Like sciatica it is often self-limited and will improve with time.

Cervical Myelopathy refers to compression of the spinal cord at the cervical level of the spinal column, which results in dysfunction that may include hand clumsiness and gait disturbance.  This can result from trauma in younger patients but more typically results from arthritic changes of the cervical spine in older adults.  Patients may report progressive clumsiness of the hands and difficulty buttoning their shirt, typing on their smartphone, and writing.  Patients may also report difficulty with ambulation and urinary retention, the latter being a late finding (Williams et al., 2022).  The progression of myelopathy is typically insidious, and patients may attribute these changes to normal aging.  Once patients begin to experience symptoms, they tend to progress in a stepwise manner.

#433 CGMs, Insulin, and How to Adjust Diabetes Meds to Glucose Patterns with Dr Jeff Colburn

• Since April 2023, CMS says any patient with 1) diabetes taking insulin at least once daily or 2) problematic hypoglycemia is eligible for a continuous glucose monitor (CGM).
• CGM metrics: Goal time-in-range 70-180 mg/dL = >70%, and below range <5%, ideally ZERO. 
• Metformin and basal insulin mainly target fasting blood glucose. GLP1 agonists and SGLT2 inhibitors lower both fasting and post-prandial glucose.
• Evaluating blood glucose patterns. Step 1: address any hypoglycemia. Step 2: target hyperglycemia addressing fasting glucose first followed by mealtime needs.
• Nocturnal hypoglycemia fixes: Reduce the basal insulin dose. If taken twice daily, omit the evening sulfonylurea dose and reduce or stop long-acting sulfonylurea agents. 
• Rapid-acting insulin should not be given between meals to avoid “stacking” doses.

Listener Voicemail #2 

Dr. Leslie Schwartz will start a concierge practice in 2025! She loves the NephMadness episodes. So do we, and we look forward to them every year!

#443 Primary Hyperparathyroidism with Dr Lindsay Kou

• Repeated serum calcium levels at or above the upper limit of normal should prompt evaluation
  • Corrected calcium is passe (Kenny, 2021)
  • Calcium and parathyroid hormone levels should be checked at the same time
  • Biotin supplementation can potentially interfere with PTH
• Thiazide diuretics are a common cause of hypercalcemia; if suspected, the thiazide should be held for three months to assess if it is a contributing factor.
  • If a thiazide is causing hypercalcemia, the patient may go on to develop primary hyperparathyroidism (PHPT).
• Primary hyperparathyroidism is the most likely diagnosis if both calcium and PTH are elevated.
• 24-hour urine calcium should be done to differentiate familial hypocalciuric hypercalcemia from primary hyperparathyroidism.
• Primary hyperparathyroid patients with hypovitaminosis D should undergo repletion to a level of at least 30 ng/dL.
• All patients undergoing work-up for primary hyperparathyroidism should undergo DEXA of the femoral head, lumbar spine, and distal radius.
• Indications for parathyroidectomy for primary hyperparathyroidism include serum calcium >1 mg/dL above upper limit of normal, skeletal involvement, renal involvement, and age <50 years.
• Normocalcemic hyperparathyroidism (normal calcium and high PTH) and normohormonal hyperparathyroidism (high calcium with inappropriately normal PTH) both carry the same surgical indications as primary hyperparathyroidism.

#440 Hepatitis B with Dr. Arthur Kim

Patients who were infected at birth will not achieve immunity from the vaccination. Additionally, prior vaccination does not guarantee immunity because the effectiveness of each vaccine is less than 100%.  Finally, risk-based screening was too complicated. Thus, it is now recommended that all adults be screened for hepatitis B once with the triple screen: HBV surface antigen, antibody, and core antibody. 

The recombinant (PreHevbrio) vaccine has been discontinued (Manufacturer’s site accessed 22 Nov 2024).

Screen and vaccinate sexual partners. Do not share toothbrushes or razors. Sharing food and drinks is probably okay. 

Protect the liver! Limit alcohol. A heart-healthy diet is a liver-healthy diet. Coffee is good for the liver (Liu, 2015). Treat patients with cirrhosis or those with significant ALT elevation and high HBV DNA. Don’t forget to screen for HCC!

Listener Voicemail #3

Amy Fishman, PA in Minneapolis. She shouts out our high-yield episode on obesity medicine with Dr. Gudzune from Johns Hopkins.

#449 Travel Medicine, Malaria, Traveler’s Diarrhea, Yellow Fever, and more! with Dr. Boghuma Titanji

• Offer refills for patients’ existing medications (and send enough to last the trip!) Assume (without judgment) that patients may be having intercourse while traveling.  Travel visits are an opportunity to offer contraceptives, condoms, and PrEP. Dr. Titanji recommends also considering offering doxy PEP for patients who meet criteria (doxyPEP is currently only approved for MSM and transgender women). You may also suggest that patients investigate appropriate travel insurance in case of unforeseen medical issues.
• Atovaquone-proguanil (Brand name: Malarone) is usually the drug of choice for malarial chemoprophylaxis. However, it cannot be used in patients who are breastfeeding or in patients with renal impairment, is not recommended in pregnancy, and should be used with caution if patients are taking warfarin (CDC 2017). 
• Traveler’s diarrhea is graded based on severity, volume, and level of impact on the person’s daily activities. Moderate traveler’s diarrhea would cause a patient to need to change their schedule based on how sick they are, whereas patients with severe traveler’s diarrhea would be so sick that they would not be able to leave their lodgings (CDC 2024).  Any bloody diarrhea (dysentery) would indicate severe traveler’s diarrhea.  It is currently recommended to treat moderate and severe traveler’s diarrhea. If a patient will be eating a lot of street food or has other risk factors, Dr. Titanji generally provides a treatment course of azithromycin for patients to take if they develop moderate traveler’s diarrhea (CDC 2024).  Ciprofloxacin and levofloxacin may be considered. However, these are not first-line in areas with increased fluoroquinolone resistance (Fernandes 2019).

#436 Endometriosis for the Internist with Drs Adela Cope and Isabel Green

1. Endometriosis (endo)  is a common condition that affects one in ten reproductive-aged women.
2. The symptoms of endometriosis can vary and may include dysmenorrhea, dyspareunia, dyschezia (pain with defecation), dysuria, pelvic pain, and other symptoms that span across organ systems.
   1. Dysmenorrhea is the leading symptom, but endo spreads to involve other organ systems over the lifespan. 
   2. A delay in diagnosis of 7-12 years is typical because of poor awareness/training/diagnostic challenges/lack of biomarkers.
3. Pelvic or transvaginal ultrasound can be utilized as an initial screening test for an individual you suspect may have endometriosis. However, normal imaging does not rule out the diagnosis of endo. 
4. Laparoscopy with a tissue diagnosis is the gold standard but not required for treatment if clinical suspicion is high.   
5. First-line treatment is often hormonal therapy, such as a combined estrogen-progestin or progesterone pills for individuals who do not desire pregnancy.
   1. Give continuous OCP to suppress menses if noncontinuous OCP therapy (includes the placebo week) is ineffective.
   2. Failure to respond to hormonal treatment does NOT rule out the diagnosis of endo. 
6. Have a low threshold to refer if the diagnosis is uncertain, abnormal imaging, fertility is desired, or symptoms are uncontrolled.  

Listener Voicemail #4

Steve is a clinical pharmacist in geriatrics and long-term care. The show has given him confidence and improved his clinical skills, especially when interacting with physician colleagues.

#447 Rhinitis and Environmental Allergies with Dr. Olajumoke Fadugba

Allergic vs Non-Allergic Rhinitis: Definitions & Classification

Important historical elements to elicit include (Bernstein 2024): 

• Onset: later adulthood suggests non-allergic rhinitis, though allergies can be developed in adulthood
• Timing: seasonal or perennial
• Triggers: particular season, weather/temperature change, strong fragrances/smells/fumes, exposures (pets, carpeting, visible mold)
• Symptoms: more common in allergic rhinitis include sneezing, ocular/nasal pruritus, sinus pressure/pain/hyposmia, and atopic symptoms (eczema and asthma). Non-allergic and allergic rhinitis can both have post-nasal drip, rhinorrhea, and nasal congestion. Understanding symptoms helps clarify diagnosis and treatment plan
• History is more important than skin testing! 

Dr. Fadugba recommends that Instead of calling everything “allergic rhinitis”, consider “chronic rhinitis” if you aren’t sure of the diagnosis!

Non-Allergic Rhinitis

Thirty to forty percent of those with rhinitis have NON-allergic rhinitis. It is more common if the onset is in later adulthood. This is a diagnosis for exclusion, so be sure to evaluate for allergies. Typical is the ABSENCE of allergy symptoms like ocular itching and sneezing but PRESENCE of rhinorrhea, congestion and/or post-nasal drip.

 Vasomotor rhinitis

• This is the most common non-allergic rhinitis.
• Triggers can be weather/season changes due to barometric pressure/temperature changes (which can be confusing because you think it is seasonal!) and strong fragrances/smells/fumes.
• Pathophysiology: imbalance in the parasympathetic/sympathetic input to the nose/sinuses. Explain to patients that this is a “migraine” of the sinuses”

Gustatory rhinitis

• Rhinorrhea with eating

 Medication-induced rhinitis

• Drug examples: estrogen/progesterone, erectile dysfunction meds, anti-hypertensives (eg vasodilators)
• Example: acute onset in older man who just start an ED medication

Immunotherapy (“allergy shots”): immunotherapy is an effective option for highly motivated patients with specific perennial allergies e.g. from pollen, or animals. The treatment is time-intensive. It involves injecting a small amount of allergen intradermally, slowly increasing the antigen dose in regular intervals (e.g., initially weekly). When the maintenance dose is reached, the treatment is monthly. The total duration of therapy is typically 3-5 years. Oral immunotherapy is available for grass, dust mites, and ragweed.

#434: Ur-INe for Recurrent UTI?! with Dr. Kellen Choi

1. Confirm the diagnosis of recurrent UTI (rUTI); three culture-positive infections in 12 months or two culture-positive infections in 6 months constitute rUTI. 
2. It’s not always a UTI; broaden the differential to include pelvic floor dysfunction, pelvic organ prolapse, genitourinary syndrome of menopause, or overactive bladder syndrome.
   1. Tenderness on palpation of the pelvic floor muscles can diagnose pelvic floor dysfunction or myofascial pain, which can be misdiagnosed as recurrent UTI.
3. Nonpharmacologic measures include proper hydration and avoidance of constipation.
4. Measures with mixed evidence for prevention include supplements like D-mannose, cranberry, and methenamine hippurate.
   1. In acidic urine, methenamine is hydrolyzed to formaldehyde and ammonia. Formaldehyde acts as a bacteriostatic agent, and hippuric acid ensures the pH stays acidic (Heltveit-Olsen, 2022).
5. Vaginal estrogen lowers the vaginal pH and improves dryness to help reduce the odds of infections.
6. Pelvic floor physical therapy can treat and alleviate symptoms that mimic rUTIs; refer to pelvic floor therapy for added benefits.

Listener Voicemail #5

Nancy Hartman, NP in Maryland. Shout out to triple therapy CCB-ARB-HCTZ recs from Dr. Jordy Cohen and knee and shoulder episodes from Dr. Ted Parks.

Links

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Goal

Listeners will recall top pearls from Curbsiders podcast 2024

Learning objectives

After listening to this episode listeners will…

1. Recall that Paul Williams is #America’sPCP
2. Gain clinical pearls and practice changing knowledge
3. Reflect on how awesome it is to practice internal medicine

Disclosures

The Curbsiders report no relevant financial disclosures. 

Citation

Williams PN, Heublein M, Watto MF. “#464 Recap Extravaganza”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date December 23, 2024.