The Curbsiders podcast

#273 ACP 2021: The Highlight Reel Part 2

May 10, 2021 | By


Binge on some delicious knowledge food fresh from ACP’s Internal Medicine Meeting 2021 #IM2021 with pearls on: primary care management of anxiety and depression, insomnia, medical marijuana, venous thromboembolism, COVID-19 and coagulopathy, syncope, diverticulitis, aspirin, and delirium!

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

Credits

  • Written, Produced, and Hosted by: Paul Williams MD, FACP; Chris Chiu MD FACP; Sarah Roberts MPH, Beth “Garbs” Garbitelli
  • Show Notes by: Beth Garbitelli
  • Cover Art: Beth Garbitelli
  • Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com

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Show Segments

Top Pearls on:

  • Primary care management of anxiety and depression
  • Insomnia
  • Medical Marijuana
  • Venous Thromboembolism
  • COVID-19 and Coagulopathy
  • Syncope
  • Diverticulitis
  • Aspirin
  • Delirium

ACP 2021 The Highlight Reel 2: Show Notes

Depression and Anxiety  Dr. Heidi Combs

Mental health disorders are incredibly common in the United States (Kessler et al 2005)  and Dr. Combs reports approximately  20% of primary care pts have at least one anxiety dx. Est. prevalence in primary care for PTSD, 5-10% Panic Disorder, 2-3% OCD, 7% social anxiety disorder (Dr. Combs presentation, Kroenke et al, 2007) The majority (80-90%) of patients with anxiety/depression are treated by primary care physicians, not psychiatrists! 

Dr. Combs Prescribing Pearls (all expert opinion):

  • Ask patient all pharmaceutical treatments they have trialed for mental health and what family members have tried. 
  • Start pt on ½ usual dose when treating for anxiety because antidepressants can cause an increase in anxiety before it starts helping–warn pts about this 
  • Titrate up; for SSRIs use lowest dose possible because will be better tolerated but may need to increase to see better outcomes and for SNRIs, better tolerated at lower doses, may not see significant benefit with higher dose 
  • Taper off benzodiazepines at 25% per week
  • Counsel/warn patients about alcohol use + benzos (CNS depression) 

Paul recommends using the Depression Medication Choice Decision Aid tool with your patients!

Insomnia

Pearls for the management of insomnia not to miss: You snooze, you lose – Christopher J. Lettieri

Insomnia is reported by ~20% of primary care patients (Shochat et al, 1999). Dr. Lettieri “Help patients re-learn how to achieve healthy sleep”:  Start with behavioral changes and positive conditioning, encourage pts to start/maintain a regimented sleep cycle- go to bed and wake up at the same time every day; ideal is for bedtime to be 8 hours before needing to be awake, and falling asleep within 15-20 minutes. Incremental changes > changing too many things at once; will take time to see benefits, requires commitment. Dr. Lettieri recommends having patients keep a progress log. CBT for insomnia (CBT-I) is first-line tx but resource-intensive, limited providers available. There are online/web-based programs, however. Consult ACP guidelines for managing chronic insomnia.  Don’t prescribe Trazodone, does not work in majority of patients per Dr. Lettieri.  Apps recommended for sleep include CBT-i: and Sleepio and recommends the books Quiet Your Mind and Get to Sleep’ by Colleen Carney.  (Sarah recommends the D-minder app to track how much vitamin D you should be getting from being outdoors!)

Cannabinoids Dr. Bree Johnston 

Moderate evidence for short-term outcomes in sleep disturbances for cannabinoids (Babson et al, 2017, Gates et al, 2017). Clustered symptoms (pain + sleep, for example may have benefit) Substantial evidence for neuropathic pain (Nugent et al, 2017) and nausea/vomiting (Cochrane 2015, IOM 2017,), moderate evidence for spasticity (Whiting et al, 2015) and sleep, but evidence for use of cannabinoids in everything else (cachexia, anorexia, anxiety, depression, PTSD, rheumatological conditions, cancer, glaucoma, Crohn’s, fibromyalgia, dementia prevention) is low to minimal. Just because we don’t have evidence yet, it doesn’t mean it’s not effective, there are simply challenges in studying it up to this point. Harm reduction strategies include counseling patients to not drive 6 hours after inhalation or 8-9 hours after oral ingestion.  Also, it is useful to know that CBD is a potent P450 enzyme inhibitor (CYP3A4, 2C19,2D16) so may impact seizure medications, warfarin , and protein-bound medications. THC is a CNS depressant so caution warranted with other such agents, as well as anticholinergics and alcohol. 

Venous Thromboembolism – Dr. Rachel Rosovsky 

Long hours of gaming are a new risk factor for DVT! 

Patients still have pretty high 3mo mortality after a massive PE: Study from 2006 (Kucher et al, 2006)  showed that massive PE 3 mo mortality rate was 52.4% and 15% non massive PE. Data from 2018 showed 3 mo mortality rate was 41.3% for massive PE, 12.3 % for submassive PE (Secemsky et al, 2018).  If you’re not commonly prescribing DOACs, look up the dosing, they’re a little complicated because they switch and some have a parental lead in. And studies show that not prescribing right dose (unsurprisingly) is not great, 10 fold higher rate of VTE recurrence (Santos-Trujillo et al, 2017). 

Cancer and DVT risk: She doesn’t use DOACs in active GI cancer (as in they have cancer in the lumen of the GI tract); she uses heparin products (Giustozzi et al, 2020). 

Outpatient tx of DVT/PE is possible! Treatment protocol combining risk-stratification, use of DOAC, and defined follow-up -> increase in # PE and DVT patients who can successfully be treated as outpatients with no increase in adverse outcomes. Mortality, bleeding, ED return were rare and did not increase after protocol (Kabrhel et al,  2018). 

COVID-19 and Clots:  47 studies, 18,093 patients- VTE Risk 17% but range was 0-85% (Jimenez et al, 2021).  In study with 400 hospitalized patients, researchers found VTE and bleeding event rates to be identical: Confirmed VTE was 4.8% non-critical patients, 7.6% in critical patients and confirmed bleed was 4.8% 7.6% both respective populations (Al-Samkari, et al, 2020). To make sense of all the guidelines, check out the  Flaczyk et al, 2020 review which attempts to make sense. Should we escalate anticoag in COVID? So far, what we know is that there’s no statistical difference between prophylaxis and therapeutic (Nadkarni, 2020) And what about post-discharge? Study evaluated 2075 COVID patients who did not have VTE during their inpatient stay who survived until discharge, only 3 (0.14%) experienced VTE post-discharge at the follow-up point (Hill et al, 2020). ATTACC, ACTIV-4a and REMAP-CAP multiplatform RCT results of interim analysis, release date Jan 28, 2021, results are pre-publication, not from locked databases, and are not peer reviewed. Preliminary findings showed therapeutic anticoag in critically ill patients did not improve organ support free days and might be harmful. But in non critically ill, there is a benefit for therapeutic anticoagulation. 

Syncope  – Dr. Daniel Dressler

Neuro testing: greater than 50% of syncope patients have neuro testing  -dx yield: 1.5% BUT would be 32% if these interventions were only in patients with neuro findings on history/phys exam (Pires et al, 2001). 

Yield of Echo in Patients with Normal History, PE, ECG: ~1%, but yield of Echo in patients with Abnormal ECG, ~17%. 

Tongue biting HIGHLY suggestive of seizure – specificity of 96%, LR+ 8.6 for seizure (Brigo et al, 2012

Use the Canadian Syncope Risk Score (CSRS) to identify patients at risk of serious adverse events w/in 30 days of ED dispo (Thiruganasambandamoorthy V, et al., 2016;  Thiruganasambandamoorthy V, et al. 2020

Diverticulitis/Diverticulosis Dr. Neil Stollman 

Younger patients presenting w/ these conditions! If managing outpatient, SELECTIVE use of antibiotics with acute uncomplicated diverticulitis (AUD) (Stollman et al, 2015). Nuts, corn, popcorn and fruits with small seeds (strawberries and blueberries) are not associated with diverticulitis risk (Peery et al, 2021)!! Bring on the berries and cracker jack!  AGA Suggests against routinely advising patients with a history of acute diverticulitis to avoid aspirin but does suggest avoidance of NSAIDs if possible (Stollman et al, 2015), specifically (>2x/week) of NSAIDs use (Peery et al, 2021). Recent dietary changes (at least in a study population of men) are beneficial and lifestyle modifications are additive / cumulative, with >50% reduction in recurrence possible with less red meat, increased fiber, normal BMI, non‐smoking and exercise >2x/week (Liu P‐H et al, 2017). Patients with recent diverticulitis (<1 yr) may be more likely to have CRC than the general population. Patients who are >50 or who had complicated diverticulitis (with abscess, peritonitis) are at increased risk of having CRC, advanced colonic neoplasia, or advanced adenoma. Colonoscopies within 1.5 to 12 months after acute diverticulitis rarely have complications. (Balk et al, 2020) Colonoscopy is advised but can be deferred if a recent (1 year) high‐quality colonoscopy was performed. Colonoscopy should be delayed 6–8 weeks (unless alarm features suggestive of malignancy) or until complete resolution of symptoms, whichever is longer (Peery et al, 2021)

Multiple Small Feedings of the Mind

General Internal Medicine – Dr. James O’Keefe and Dr. Rachel Brook

Round-up of Aspirin for Primary Prevention (ARRIVE, ASPREE, ASCEND, Zheng et al, 2019 JAMA Meta-anlysis (13 trials) . Highlights include: Reduced CV event (NNT 265), Increased major bleeding (HR 1.43, NNH 210) and No difference in all-cause or CV-related mortality. ACC/AHA Guidelines 2019 determined that for “Primary prevention -> Lack of net benefit” Statifying NNT by CAC score. High CAC >100, then ASA benefits may outweigh bleeding risks (Miedema et al, 2014). 

Delirium – Dr. José Maldonado 

One day of delirium in the ICU increases the hazard of mortality by 10% (Maldonado et al, 2013, Maldonado et al, 2018) !!!  Hypoactive delirium is predominant and most often missed. S-PTD (Stanford Proxy Test for Delirium) nursing based screening (vs direct pt participation) -> 92% overall diagnostic accuracy (Alosaimi et al, 2018, Maldonado et al, 2020). Non-pharm interventions are critical and early mobilization is probably the most important (Scheweickert, et al, 2009). Consider 3mg Melatonin -> 10mg if the patient still becomes delirious. Melatonin is physiologically active for approximately 12hours (9pm -> peaks at 1am -> disappearance 9am), try to give it early to match that physiologic state.  Alpha2-Agonists (Precedex/Dexmedetomidine, Guanfacine) act on endogenous sleep pathways and enhance deep sleep without affecting REM sleep(Nelson et al, 2003). Dexmedetomidine is better than propofol and midazolam(Maldonado et al, 2003, Maldonado et al, 2009). Guanfacine is oral and doesn’t need ICU monitoring, but takes 3 days to get to steady-state.  


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…  

  1. Become familiar with the latest research in psychiatry,  primary care,  hematology, gastroenterology, hospital medicine,  and geriatric medicine
  2. Update themselves on new or modified guidelines related to the treatment of acute and chronic conditions common in primary care and hospital settings  
  3. Reflect on the role of the internist in providing mental health care in outpatient settings.

Disclosures

The Curbsiders report no relevant financial disclosures. 

Citation

Roberts SP, Williams PN, Chiu CJ, Garbitelli EC. “#273 ACP 2021: The Highlight Reel Part 2”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date May 10, 2021.

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The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.

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