#272 ACP 2021: The Highlight Reel Part 1

Binge on some delicious knowledge food fresh from ACP’s Internal Medicine Meeting 2021 #IM2021 with pearls on: Heart Failure, Hypertension, IV vs PO antibiotics, Hepatology, Kiwifruit for constipation, Perioperative Sleep Apnea, Thyroid, Bariatric Surgery, Neurology, Super Gonorrhea, and more!

Note: This episode will not be available for CME/MOC credit due to the rapid turnaround time.

Credits

Written, Produced, and Hosted by: Deborah Gorth; Paul Williams MD, FACP; Matthew Watto MD FACP; Avital O’Glasser MD, FACP; Molly Heublein MD
Show Notes by: Matthew Watto MD
Cover Art: Beth Garbitelli
Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com

Sponsor: Panacea Financial panaceafinancial.com

Sponsor: GeriPal GeriPal.org

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Show Segments

Top Pearls on:

Heart Failure
Oral vs IV antibiotics for osteomyelitis, bacteremia, and endocarditis
Inpatient Blood Pressure Management
Perioperative sleep apnea
Thyroid pearls (pregnancy and weekly dosing)
Bariatric Surgery pearls
GI disorders (Cdiff, constipation, diverticulitis)
Super Gonorrhea; Sunscreen!
Outro

ACP 2021 The Highlight Reel: Show Notes

Deb’s Pearls

Update in Cardiology– Dr. Clyde Yancy

SGLT2 inhibitors are a heart failure drug (DAPA-HF), NNT = 21, and have beneficial effects on kidney function (DAPA-CKD). Empagliflozin shows synergistic diuretic effects when given with bumetanide without evidence of potassium wasting or neurohormonal activation (Griffin et al 2020). Not surprisingly SGLT2 inhibitors are now recommended as a first line therapy for heart failure, and achieving target/maximally tolerated doses of ARNI/ACEi/PRB is not necessary before adding SGLT2 (2021 Update to ACC Guidelines). We are now awaiting the results of the EMPEROR-Preserved Trial to see if they are effective in HFpEF.

Advances in Inpatient Heart Failure– Dr. Clyde Yancy

In patients with worsening HF, sotagliflozin initiation before or shortly after discharge results in lower mortality and hospitalizations (SOLOIST-WHF). Data showing synergistic diuretic effects of loop diuretics and SGLT2i without evidence of potassium wasting or neurohormonal activation (Griffin et al 2020).
Potential role for iron replacement in reducing the risk for future hospitalization [EF <50%; ferritin <100 ug/L or 100-299 ug/L and transferrin saturation <20%]. These patients received IV ferric carboxymaltose (weight and Hb based dosing p15 supplemental) during hospitalization, six weeks following hospitalization, and at longer intervals (AFFIRM-AHF). There are ongoing clinical trials to further investigate the utility of iron therapy in HF patients with iron deficiency.

Oral antibiotics vs IV – Dr. Brad Spellberg

Is IV needed for osteomyelitis, bacteremia, and endocarditis?

IV antibiotics for clinically stable patients with osteomyelitis, bacteremia, and endocarditis patients. All available controlled studies show oral antibiotics are safe and effective. Oral antibiotics noninferior to IV when used during the first 6 weeks for complex orthopedic infection as assessed by treatment failure at 1 year (OVIVA). Oral therapy vs IV for endocarditis [left sided in stable condition] noninferior (POET). Dr. Spellberg has a great website referencing all relevant research.

Update in hospital medicine – Dr. Dustin Smith

Don’t muck around with blood pressure medication in the hospital for individuals there with non-cardiovascular conditions. Inpatient hypertension treatment associated with higher rates of AKI and MI, and inpatient intensification of HTN meds did not result in better outpatient BP control (Rastogi et al 2020). Similar results have also been shown in older adults (Anderson et al 2019).

GIM ‘Multiple Small Feedings’– Dr. James O’Keefe

Sunscreen counseling towards titanium dioxide and zinc oxide. Some organic compounds are now banned in Hawaii (Mohammad and Lim 2021). I had no idea about there being any sunscreen issues, but just bought some mineral based sunscreen for my pre-intern year sun exposure.

Avi’s Pearls

Ambulatory General Internal Medicine

Perioperative Obstructive Sleep Apnea – 2019 POSA study

The perioperative state unmasks/exacerbates OSA physiology
OSA is associated with increased risk of pulmonary complications postop
Authors hypothesized that unrecognized OSA would be associated with increased cardiovascular risk postop
- Primary endpoint: MI, CV death, CHF, VTE, AF, new stroke
67.6% had unrecognized OSA; 11.2% had severe OSA
Results/Conclusions:
- Unsuspected OSA is very common periop
- Severe OSA was associated with significantly increased CV events
- All degrees of OSA were associated with increased risk of unplanned ICU (re)admission
Study did not explore if preop sleep studies improved outcomes
BIG question = Do you delay elective (or non-elective) surgery for sleep study versus empirically manage?
- Argument in favor of relative ease of getting home sleep studies…but how easy is this actually?
STOP-Bang
- >= 3 predicts higher risk of OSA
- sensitivity/specificity of STOP-Bang for predicting severe OSA increases with higher STOP-Bang scores (Chung et al 2012; Chung et al 2015)

Geri pearls Dr. Eric Widera

The prescribing cascade is a clinical challenge, especially for geriatric patients
CCB are one of the most commonly prescribed antiHTNive
Peripheral edema occurs in 2‐25% of patients and is dose‐dependent
- Due to extravasation of intravascular fluid due to arteriolar dilatation increasing the pressure gradient between arteriolar and venule capillaries (see also amazing Tony Breu Tweetorial about this mechanism of action)
A notable number of geriatric patients who are prescribed CCB end up on furosemdie for LE edema (Savage et al 2020)
- 10% of patients on CCB develop edema, and 7-14% of those patients end up on a loop diuretic
De-prescribing is a very important consideration v pursuing new medical diagnoses (Piggott et al 2020)
De-prescribing tools exist

Molly’s Pearls

Thyroid disorders Dr Douglas Paauw

In early pregnancy (likely before pt sees ob/gyn) important to increase levothyroxine dose. Just add 2 pills per week of her current dose (Yassa 2010).
Pts with H. pylori infection, atrophic gastritis, or PPI use had 22-37% higher doses of levothyroxine- pH impacts absorption! (Centanni 2006)
Pts with adherence issues can take a once-weekly dose of their full weekly requirement (Jayakumari 2019)
USPSTF grade D recommendation for thyroid physical exam (USPSTF 2017)

Outcomes after Bariatric Surgery Dr Wee

“Metabolic surgery should be considered as an option for adults with type 2 diabetes and BMI 30.0–34.9 kg/m2(27.5–32.4 kg/m2 in Asian Americans) if hyperglycemia is inadequately controlled despite optimal medical control by either oral or injectable medications (including insulin). B” (ADA 2018).
Following Roux-en-Y gastric bypass, thirty percent of bypass patients come off HTN meds (vs 2% placebo). No change in HTN control. (Schiavon 2020)

Clinical Trial: Lower GI

Diverticulitis – Dr. Stollman

Ok to treat uncomplicated diverticulitis without antibiotics! AHRQ BPA 2: Studies did not find that antibiotic treatment resulted in differences in pain, length of stay, recurrence risk, or QOL, but may reduce need for surgery compared to no antibiotic treatment (AHRQ 2020)
AGA practice update 2021: NSAIDS should be avoided to help reduce the risk of diverticulitis (Peery 2021)

Constipation – Dr. Rao

Not all constipation is IBS-C. Think about slow transit disorders and evacuation problems.
You can diagnose pelvic dyssynergy on rectal exam. (Tantiphlachiva 2010) It has good correlation with more invasive testing like anal manometry or balloon expulsion test!
Digital maneuvers: Check for mass, tenderness, stool. Squeeze x 2: Assess if normal, weak, increased. Bearing down x 2 push effort, sphincter relaxation, perineal descent. Clinically dyssynergy if any 2 of: inability to contract abdominal muscles, relax anal sphincter, paradoxical contraction of anal sphincter, absence of perineal descent. Biofeedback can be quite effective in these patients. (Rao 2010)

Cdiff – Dr. Kelly

C diff Colonization rates are high: 1‐3% healthy adults; 4‐29% hospital inpatients; 50% residents of long‐term care facilities.
Post‐infection IBS common (25%) after CDI. Clues: Non‐response to vancomycin, symptoms up/down, “different” than initial CDI. Furuva‐Kanamori et al BMJ Inf Dis 2015 Wadwa A. et al. Alimen Pharmacol Ther 2016
20-30% chance of 1st recurrence. Patients who have already had 2 recurrences: 40% recurrence.

Paul’s Pearls

Neurology Pearls – Dr. Andrea Leep Hunderford

Rapid eye movement sleep behavior disorder (RBD)

Characterized by dream reenactment
Most RBD is idiopathic above age 50 years old (often precedes a neurodegenerative diagnosis
Under 50 years old think about secondary causes
Secondary causes include: Medication related (Especially antidepressants), narcolepsy, structural pontine lesions, paraneoplastic or autoimmune disorder. (St. Louis EK Mayo Clin Proc 2017)

Lewy Body Dementia

Acetylcholinesterase inhibitors, especially donepezil, have been shown to improve cognition, reduce fluctuation, and enhance ADLs (Taylor JP Lancet Neurol 2019; Samuel W Int J Geriatr Psychiatry 2000)

GI and Hepatology – Dr. William Sanchez

IPMNs

IPMNs can grow and progress to pancreatic cancer.
Surgical management is a Whipple procedure. This is a huge surgery, even in healthy patients
Surveillance should be discontinued in patients who are not candidates for surgical intervention (SS Vege Gastroenterology 2015)

Drug Induced Liver Injury (DILI)

Many prescriptions and OTC meds can cause DILI (Lee WM N Engl J Med 2003; Leise MD Mayo Clin Proc. 2014)
Most drugs have a signature toxicity pattern. Includes: cholestatic, hepatocelluluar, micro- or macrosteatosis, veno-occlusive disease, or drug-induced autoimmune hepatitis.
No specific diagnostic test, but positive antinuclear and anti-smooth muscle antibody suggest drug-induced autoimmune hepatitis (seen with Nitrofurantoin, Alpha-methyldopa, Hydralazine)
Livertox.nih.gov is an excellent resource

Alcohol associated liver disease

Patients with prior gastric bypass surgery at higher-risk for alcohol-related liver disease/injury (White GE Annals of Surgery 2019)

Watto’s Pearls-

GI Updates Dr. Amy Oxentenko

Cecal intubation rate (>95%), withdrawal time >=6min, and adenoma detection rate of at least 25% are quality measures that should be assessed (Gupta Am J Gastroenterol 2020).
Follow-up 7-10 years for low-risk adenoma(s), and 10 years after normal surveillance Cscope (Gupta Am J Gastroenterol 2020).
Peppermint for IBS! Okay, Paul. It was conditional and low certainty (Lacy Am J Gastroenterol 2021).
BUT, what about Kiwifruit? It works nearly as well as Psyllium, and Prunes for chronic constipation! (Chey Am J Gastroenterol 2021).
IBD meds can be continued in pregnancy (PIANO trial)! Uncontrolled disease associated with increased spontaneous abortions (Mahadevan Gastroenterol 2021).

ID Updates Dr. Fred Lopez

Beware SUPER Gonorrhea! The new rec is for Ceftriaxone 500 mg IM x1 (prior rec Ceftri 250 mg, azithro 1gm). Rationale: To achieve higher MIC for ceftriaxone and because of high rates azithro resistance (Sancta MMWR 2020)

Goal

Listeners will learn about a variety of topics in primary care and hospital medicine that were presented at the ACP Internal Medicine Meeting 2021 (#IM2021) virtual conference.

Learning objectives

After listening to this episode listeners will…

Become familiar with the latest research in gynecologic care, reproductive health, primary care, young adult, hospital, perioperative and geriatric medicine
Update themselves on new or modified guidelines related to the treatment of acute and chronic conditions common in primary care and hospital settings
Reflect on the role of the internist in providing equitable healthcare access to vulnerable or underserved patient populations

Disclosures

The Curbsiders report no relevant financial disclosures.

Citation

Roberts SP, Williams PN, Chiu CJ, Berk J, Raymond-Kolker B, Watto MF. “#270 SGIM 2021: The Highlight Reel”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date April 26, 2021.

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