#75: Recap, highlights, and clinical pearls extravaganza for The Curbsiders 2017

December 25, 2017 | By Matthew Watto, MD

Join us for this recap of the key clinical pearls and favorite fan voted episodes from 2017 including: lipids, asthma, diuretics, hyponatremia, CKD, vertigo, and dizziness. Plus, Picks of the Year, exciting announcements for 2018, and Paul reveals that he has a wife! Matt, and Paul are joined by Curbsiders Correspondent, Dr. Chris Chiu, who wrote and produced this episode. Stuart was out with the Man Flu. My apologies to Dr. Bryan Brown whose name I forgot to shout-out when listing our Correspondents.

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Picks of the Week:

1. Chris’ Pick – The Dantastic Mr. Tox & Howard Show
2. Paul’s Pick – Every Frame a Painting: Hollywood Scores & Soundtracks, or Snowpiercer – Left or Right

Picks of the Year

1. Matt’s Pick – Vancomycin and pip-tazo combo has increased AKI risk (Luther MK Crit Care Med 2018). Also check out Dr. Paul Sax’s Blog Post on the subject
2. Paul’s Pick – PROCIRCLE Speed Jump Rope (From Episode 59)
3. Chris’ Pick – Podcast IM Reasoning “Turning the Wheel” (and Part 2)

Favorite Fan voted Episodes and Clinical Pearls

Episode #65: Scott Weingart of EMCrit on Emergency vs Internal Medicine: The Devil of the Gaps

1. Blast away anchoring bias: Don’t get a story unless the patient is sick. Asking too many questions forces EM doc to make things up.
2. The Devil of the Gaps: Post-test probability (PTP) of serious disease after a workup in ED: Between 10-100%, everyone happy to admit patient. Between 2-10%, IM says WTF!, but DC too risky. Between 0-2%, DC home. Low risk, but lawyers may still sue if something bad happens.
3. The under 2% miss rate is from the PE literature. Article about PERC rule from Annals Emergency Medicine in 2010.

Episode #37: Lipids PCSK9, and ezetimibe: Lower is better

1. AACE-ACEG Treatment guidelines emphasize importance of treating LDL to certain goals.
2. ACC/AHA 2013 Cholesterol guidelines expect ≥50% reduction of LDL for high-intensity statins, 30-50% for moderate intensity statins.
3. IMPROVE-IT Trial: Ezetimibe plus statin versus statin plus placebo. Cardiovascular events lowered in ezetimibe plus statin group (average LDL of 53) versus high dose statin alone.
4. FOURIER Trial: Statins alone (median LDL in 92) versus statins plus PCSK9 inhibitor (median LDL 30). No decrease in CV death over 2.2 years, but 1.5% absolute risk reduction in composite CV events (acute coronary syndrome, stroke, revascularization).
5. MESA Calculator is recommended by AACE guidelines and uses a CAC score. Is better for evaluating individualized risk.
6. We talked more about Coronary artery calcium scoring in Episode #28 with our expert guests from The Society for Cardiovascular Computed Tomography. Can help us evaluate patients with increased family risk which is not taken into account with the ASCVD risk calculator.
7. Similarly, we discussed Coronary CT angiography (CCTA) with our SCCT guests in Episode #46. Controversy with CCTA is that it may lead to more revascularization…BUT less patients sent for left heart cath inappropriately [i.e. have non-obstructive coronary artery disease (CAD)]. CCTA is useful for our EM colleagues who don’t want to admit a patient overnight just for a stress test. Rory Spiegel (@EMNerd_) has a great discussion on his blog.

Episode #71: Asthma Made Simple

1. Stepwise Therapy:
2. Don’t be afraid to de-escalate therapy if a patient is well controlled.
3. Advising patients to avoid triggers is critical in disease management. Common triggers include: Dry air, cold air, exercise, cooking, chemicals, detergents. These can all lead to bronchospasm!
4. Keep an eye out for your patient’s formulary. If their inhalers change, you may need to reteach inhaler technique.
5. Spirometry should be normal in asthma, especially in-between exacerbations. If abnormal, then either they are in the middle of an exacerbation, asthma is not well controlled, or patient has something else altogether
6. Encourage liberal use of short acting bronchodilators – use it as often as needed in exacerbation. In the ED patients get CONTINUOUS albuterol nebs! Check out Intermountain Healthcare’s Asthma Action Plan.
7. Azithromycin: useful if a patient has frequent exacerbations (as maintenance therapy) but not useful as empiric therapy for acute exacerbations. Studies have also shown some benefit for prevention of exacerbations in refractory COPD. Also, azithromycin is not recommended for empiric therapy for sinusitis. Please also see Episode #54 on URIs with Dr. Centor.

Episode #49: Vertigo and Dizziness: How to Treat, Who to Send Home and Who Might Have a Stroke

1. Classification of dizziness: Don’t focus on type e.g. vertigo, presyncope, unsteadiness, non-specific other type of dizziness. Focus on timing, triggers, and targeted exam i.e. timing of dizziness, and what triggers the dizziness. These inform the appropriate choice of physical exam maneuvers e.g. Dix Hallpike versus HINTS.
2. Buckets: episodic, acute, or chronic vestibular syndromes
   1. Episodic vestibular syndrome: Acute vertiginous symptoms present for under 12 hours (usually seconds or minutes). Can be triggered, or spontaneous. Differential diagnosis = benign paroxysmal, positional vertigo (BPPV), vestibular migraine, and Meniere’s disease. If symptoms occur spontaneously (i.e. NOT triggered), then transient ischemic attack must be considered!
   2. Acute vestibular syndrome: Persistent vertiginous symptoms 12 hours or more. Differential diagnosis = vestibular neuritis (aka labrynthitis if associated hearing loss) versus stroke.
   3. Chronic vestibular syndrome: Symptoms of vertigo lasting one month or more. Many patients had a previous acute vestibular syndrome and never fully recovered. If insidious onset, then suspect an underlying primary neurologic disorder. Some patients have an “anxiety” component w/o underlying pathology (diagnosis of exclusion).
3. Canalith Repositioning: Diagnose posterior canal BPPV with Dix-Hallpike and Treat with Epley maneuver. Horizontal canal BPPV is diagnosed with supine roll test and treated with the Lempert roll maneuver (Figure 5).
4. With Meniere’s disease, meclizine is a reasonable choice if limited to 3 days. (Dr Newman-Toker’s expert opinion)
5. With Vestibular neuritis, treatment with benzodiazepines or meclizine should be limited to 3 days as well. (Dr Newman-Toker’s expert opinion)
6. Head impulse test (HINTS exam): Have patient fixate on a midline target (e.g. examiner’s nose). Next, rotate head rapidly 20 degrees to right or left. Then, bring head back to midline. Normal if eyes remain fixed on target. Abnormal if eyes are dragged off target, followed by a saccade back to the target. An abnormal test suggests a peripheral lesion. A normal head impulse test in a patient with an acute vestibular syndrome suggests a stroke.

Episode #31: Diuretics, leg cramps, and resistant hypertension with The Salt Whisperer

1. Chlorthalidone is more potent, and longer acting than hydrochlorothiazide. Starting dose 12.5 mg once daily in morning. Consider every other day dosing if frail, multimorbidity, or just poor compliance.
2. Leg cramps: try 1 tablespoon of pickle juice as needed for nocturnal leg cramps. SELL IT WITH CONFIDENCE
3. Diuretic resistance: Can be two types.
   1. First, either the dose is not high enough or the route is wrong (IV needed if severe gut edema). If diuresis is not good enough at one hour, consider increasing and redosing within the next hour and you don’t have to worry about dose stacking.
   2. The second type, is where patient has initially good diuresis but it wears off and diuresis not adequate at 24 hours. Consider treating with more frequent dosing.
4. Resistant HTN: Ratio of plasma aldosterone concentration:plasma renin activity >20 (ratio does not hold for newer renin assays), or an aldosterone level >15 with suppressed renin suggests primary hyperaldosteronism [OKAY to check even if on ACEI/ARB/diuretic, but not if on aldosterone antagonist]
5. Treatment of Resistant HTN: If BP uncontrolled despite at least 3 drugs (including a diuretic), then add spironolactone next.
6. Furosemide (Lasix) dosing by expert opinion:
   1. Topf dosing = Cr times 20
   2. House of God dosing = age + BUN
   3. Dr. Adler’s dosing from our CHF episode = BUN times 2
   4. Also you definitely CAN overdose someone on a diuretic.

Episode #48: Hyponatremia Deconstructed

1. Volume status: Physical exam can help for grossly hypo- or hypovolemic patients, but euvolemia can be difficult to differentiate from mild hypovolemia, or hypervolemia. According to this study from the American Journal of Medicine in 1987, our clinical assessment of volume status in hyponatremia is not very good. Elevated specific gravity, or low urine sodium (<30 mmol/L) suggest either true hypovolemia, or low effective arterial volume (e.g.h heart failure).
2. SIADH: Diagnosis of exclusion. Urine osmolality >300 mmol/L. Check thyroid panel, cortisol. Patients have very low urine outputs. ADH dramatically lowers water excretion.  Thus, water intake easily exceeds water output. SIADH is often transient and due to stressors e.g. lung disease, surgery, trauma. If persistent, then look for causes like CNS or lung disease, and consider imaging. Treatment is fluid restriction, increased solute load (with salt tabs, or Ure-Na), and low dose loop diuretic (blunts action of ADH by altering medullary concentration gradient for water).
3. Rate of fluid correction: If severe and symptomatic hyponatremia (usually Na+ <115), then consider DDAVP clamp (administration of ADH) with IV hypertonic saline. Goal 5 mEq rise in sodium immediately and 10 mEq in first 24 hours. Should be done in ICU. If mild and asymptomatic hyponatremia, then goal 6 mEq rise in sodium per day (Max is 12 per day or 0.5mEq per hour). Shooting for 6 mEq gives a buffer. Also check out Josh Farkas’ great discussion on the DDAVP clamp on his PulmCrit Blog.
4. Solute ingested each day (aka solute load) = Solute excreted under normal conditions. 1 mmol/L = 1 mOsm/kg. Solute is excreted via urine, which can be diluted to minimum of 50 mmol/L (minimum urinary concentration), or concentrated to maximum 1200 mmol/L (or 1200 mOsm/kg). E.g. 60 kg person ingests about 10 mOsm/kg/day = solute load of 600 mOsm/day that must be excreted. So, a solute load of 600 mmol divided by minimum urine concentration of 50 mmol/L = 12 L urine output. Thus if this person ingest 13 L water then 1 L cannot be excreted and sodium will fall.
5. If tea and toast diet or beer drinkers potomania eating 100 mmol/day solute and minimum urinary concentration of 50 mmol/L, then max urine output is 100 mmol/day divided by 50 mmol/L = 2 L/day maximum water excretion. If this person ingests >2 L/day then sodium will fall.

Episode #67: CKD Pearls and Episode #69: CKD Prescribing Do’s and Don’ts

1. Refer patients to nephrology if
   1. You feel uncomfortable
   2. Persistent hematuria
   3. eGFR < 30
   4. Significant proteinuria (>2gm/day)
   5. Uncontrolled hypertension
2. Metformin is OK to use until estimated GFR is under 30 ml/min
3. Low protein diet in CKD is controversial: UpToDate suggests possible benefit, but many Nephrologists (like Dr Topf) disagree with this interpretation of the data. Read more at this post from #NephMadness 2017.
4. Is the American diet protein heavy (as Paul believes) or carbohydrate heavy (as Matt believes)? Please vote here and list your references!

Miscellaneous

1. As we discussed in Episode #23, obesity is a DISEASE and not a lifestyle choice. Similarly, we also discuss addiction as a disease in our recent episodes #73 and #74. Both will likely need lifelong therapy.
2. In Episode #72 on transgender care, we discussed how the old terminology of gender identity disorder from DSM-IV is no longer used or preferred. The term “disorder” has been removed. The term gender dysphoria should be used to describe individuals who experience significant distress due to a discordance between their unique gender identity and their sex assigned at birth.
3. Per Paul, in talking to our experts, a prevailing theme of advocacy seems to be there. It always goes back to shared decision making and meeting a patient “where they are”.
4. Another recurring theme that Paul notes is “just get a history” e.g. in asthma or in evaluation of volume status, you need to talk to the patient and get the story directly from them.
5. Paraphrase: “Fundamentally, as healthcare providers our jobs at the end of the day is to make patients feel better and promote their health.” -Dr. Paul Nelson Williams

Goal: Listeners will learn that The Curbsiders is a spectacular high-yield Internal Medicine Podcast and feeding knowledge food to your brain hole feels so good.

Learning objectives:

After listening to this episode listeners will…

1. Learn some EM and heuristic pearls
2. Learn some Lipid pearls
3. Learn some Asthma pearls
4. Learn some Vertigo pearls
5. Learn some Nephrology pearls
6. Become better healthcare providers

Disclosures: The Curbsiders report no relevant financial disclosures.

Time Stamps

• 00:00 Intro
• 01:18 Getting to know Chris Chiu introduction
• 03:07 Picks of the week and
• 06:10 Picks of the year and discussion of vancomycin and pip-tazo causing AKI
• 11:41 Recap of Scott Weingart and EM vs IM episode
• 17:45 Discussion of Lipids, PCSK9, CAC, CCTA
• 27:10 Asthma pearls recapped
• 32:43 Dizziness and vertigo recapped
• 38:40 Diuretics, diuretic resistance, and secondary hypertension diagnosis and treatment
• 44:35 Diuretic dosing
• 46:25 Hyponatremia, volume status, solute loads and SIADH
• 50:08 CKD, when to refer, and an argument about low protein diets
• 54:25 Matt, Paul, and Chris reflect on important lessons learned from 2017
• 59:32 Listener questions and comments
• 63:35 Wrap-up, and shout outs
• 66:22 Announcements for 2018
• 67:25 Outro

Links from the show:

1. https://itunes.apple.com/us/podcast/the-dantastic-mr-tox-howard/id1247074688
2. https://www.youtube.com/user/everyframeapainting
3. Hollywood Scores & Soundtracks: What Do They Sound Like? Do They Sound Like Things?? Let’s Find Out!
4. Snowpiercer – Left or Right
5. Luther MK et al. Vancomycin Plus Piperacillin-Tazobactam and Acute Kidney Injury in Adults: A Systematic Review and Meta-Analysis. Critical Care Med 2018
6. Two Quick Thoughts Inspired by Inpatient ID Consults, and An Inspirational Baseball Poster by Dr Paul Sax on his HIV and ID Observations Blog
7. Jump Rope from Amazon https://www.amazon.com/PROCIRCLE-Speed-Jump-Rope-Adjustable/dp/B01AVV3E5U
8. IM Reasoning podcast #33 http://imreasoning.com/episodes/episode-33-turning-wheel-part-1-glenn-colquhoun/
9. IM Reasoning podcast #35 http://imreasoning.com/episodes/episode-35-turning-wheel-2/
10. Curbsiders podcast with Scott Weingart of EMCrit http://thecurbsiders.com/internal-medicine-podcast/65-scott-weingart-emcrit-emergency-versus-internal-medicine-devil-gaps
11. Article suggesting 2 percent miss rate might be acceptable. Testing low-risk patients for suspected pulmonary embolism: a decision analysis.
12. Curbsiders podcast on Lipids and PCSK9 http://thecurbsiders.com/podcast/s2-e15-lipids-pcsk9-ezetimibe-lower-better
13. AACE Lipid guidelines 2017 https://www.aace.com/files/lipid-guidelines.pdf
14. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults
15. IMPROVE-IT Trial. Ezetimibe Added to Statin Therapy after Acute Coronary Syndromes. NEJM 2015
16. FOURIER Trial. Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease. NEJM 2017
17. MESA CHD Risk Calculator
18. Curbsiders episode on CAC scoring
19. EM Nerd Rory Spiegel discusses CCTA and the PROMISE trial for evaluation of Chest Pain
20. Curbsiders Asthma episode
21. Asthma Action Plan from Intermountain Healthcare
22. Use of chronic azithromycin to prevent asthma exacerbations Azithromycin and Asthma exacerbations
23. Negative trial using azithromycin for asthma exacerbations Azithromycin for Acute Exacerbations of Asthma The AZALEA Randomized Clinical Trial
24. Azithromycin for Prevention of Exacerbations of COPD. NEJM 2011
25. IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. 2012
26. Curbsiders Upper Respiratory Tract Infections episode
27. Dr Newman-Toker’s video Dix-Hallpike test for the left posterior semicircular canal
28. Dr Newman-Toker’s video Posterior Canal – BPPV: Epley and Semont maneuvers
29. Dr Newman-Toker’s video 3-Component H.I.N.T.S. battery
30. Diagram for horizontal canal BPPV therapy see Figure 5 http://www.neurology.org/content/70/22/2067.figures-only
31. Curbsiders episode on diuretics and resistant hypertension with Dr Joel Topf
32. Curbsiders episode on heart failure with Dr Eric Adler
33. Article showing clinical volume status exam inferior to lab testing https://www.ncbi.nlm.nih.gov/pubmed/3674097
34. EMCrit article discussing DDAVP https://emcrit.org/pulmcrit/taking-control-of-severe-hyponatremia-with-ddavp/
35. Curbsiders #67 on CKD with Joel Topf and CKD part 2 with Joel Topf
36. Low protein diet article from UpToDate
37. NephMadness entry on low protein diets https://ajkdblog.org/2017/03/07/nephmadness-2017-nutrition-region/amp/
38. Settle the dispute between Matt and Paul regarding protein content in the American diet Help us decide which Curbsider is Correct?
39. Curbsiders episode on obesity
40. Curbsiders episode #73 on opioids
41. Curbsiders episode #74 on clinical cases of opioid use disorder
42. Curbsiders episode #72 on transgender care in primary care
43. The Curbsiders fledgling YouTube Channel
44. Chris in his Stormtrooper helmet and wearing Curbsider swag: https://www.instagram.com/p/BcXfoRtBgAJ/