#43 Random Clinical Pearls: ACP Highlights and Recap Part 2

June 12, 2017 | By Matthew Watto, MD

Load up on clinical pearls for your practice in this wide ranging discussion with expert clinician educator, Dr. Jon M. Sweet, Associate Professor of Medicine from Virginia Tech Carilion School of Medicine. Topics include cellulitis, tinea infections, dermatologic emergencies, smoking cessation, heart failure, hormone replacement therapy, iron supplementation, and vocal cord dysfunction. Plus, Stuart gives Paul a new nickname! Special thanks to the Dr. Patrick Alguire and Dr. Darilyn Moyer from the American College of Physicians for setting up this episode.

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Clinical Pearls:

1. Advice for MedEd: As a learner: Read something everyday (even 5 minutes is helpful)! As a teacher: Think out loud and invite everyone to participate on rounds, and don’t be afraid to say, “I don’t know”.
2. Tinea infections: Use terbinafine (or another allylamine) as first line for tinea pedis, cruris, and corporis. Allylamines are fungicidal. Topical azoles are fungistatic.
3. Cellulitis: 30% of cases are misdiagnosed. Three general rules for cellulitis: Unilateral, acute onset, and rapid response to antibiotics. If these 3 rules are not met, then consider another diagnosis +/- a dermatology consult. Differential includes: deep vein thrombosis; contact, irritant or allergic contact dermatitis; insect bite/sting; and many more (see Cellulitis: A Review JAMA 2016 below).
4. AGEP: Acute, generalized, exanthematous pustulosis that starts w/in 2-3 days of culprit medication (e.g. CCB, penicillins, macrolides, others). Benign “nuisance” condition. Stop offending agent and prohibit future use. Use medium potency topical steroid as needed.
5. DRESS: Drug reaction with eosinophilia and systemic symptoms onset w/in 3-4 weeks of culprit medication (e.g. anti-epileptic drugs, allopurinol, many others). Dangerous condition with 10% mortality! Can mimic sepsis. Skin rash varies, but facial edema characteristic. Features: Low grade fever, facial edema, transaminase elevation, acute interstitial nephritis. Tx: Start high dose prednisone (e.g. 1 mg/kg/day) with slow taper over and consult dermatology.
6. Tobacco/Smoking Cessation: “Cold turkey” aka abrupt cessation provides higher abstinence rate than gradual taper.
7. Low back pain: Acetaminophen (paracetamol) ineffective. NSAIDS first line. No benefit with addition of cyclobenzaprine, or opioid pain medications. ACP 2017 guidelines recommend nonpharmacologic therapies e.g. PT, tai chi, yoga, acupuncture, chiropractor, etc.
8. Hot flashes: No increased stroke risk with transdermal estrogen, and oral micronized progesterone.
9. Iron deficiency: Preferred iron dosing is thrice weekly (e.g. Mon, Wed, Fri) based on Blood 2015 article by Moretti due to 48 hour rise in hepcidin, which blocks absorption. Check for 1 gm increase in hemoglobin after 3 weeks on iron thrice weekly dosing.
10. Iron deficiency in CKD: KDIGO ferritin target = >500, up to Hgb 11.5 gm, transferrin saturation >30%. Patients often require IV iron supplementation.
11. ARNI: Inhibit breakdown of neprilysin causing increased BNP (natriuretic peptide). Reasonable to replace ACEI with ARNI if chronic NYHA II-III (Class I, Level B-R from ACC/AHA 2017 guidelines)
12. Vocal cord dysfunction (VCD): May present like status asthmatic except lung volumes LOW in VCD instead of hyperinflated. Usually “asthma like” story with exposure to an irritant. May fail to respond to typical asthma therapy. Diagnosis: Clinical +/- observed paradoxical motion of the vocal cords.

Goal:
Listeners will incorporate clinical pearls learned at the 2017 American College of Physicians Internal Medicine Meeting.

Learning objectives:
By the end of this podcast listeners will:

1. Recall that cellulitis is often misdiagnosed and broaden the differential diagnosis
2. Choose the appropriate agent for tinea infections
3. Recognize the presentation of acute generalized exanthematous pustulosis (AGEP)
4. Recognize and treat DRESS (drug reaction with eosinophilia and systemic symptoms) syndrome
5. Choose the most effective strategy for smoking cessation
6. Employ effective therapies for acute and chronic back pain
7. Avoid over supplementation with iron
8. Be aware of new treatments for heart failure
9. Recognize vocal cord dysfunction as a potential mimic of asthma

Disclosures:
Dr. Sweet reports no relevant financial disclosures.

Time Stamps
00:00 Intro
02:12 Picks of the week
05:10 Guest intro
07:13 Rapid fire questions
15:25 Tinea infections
18:22 Misdiagnosis of cellulitis
23:53 AGEP (Dermatology)
29:03 DRESS syndrome (Dermatology)
35:28 Smoking cessation
36:55 Back pain, acetaminophen and acupuncture
41:42 Hot flashes and hormone therapy
43:05 Iron supplementation
49:55 Heart failure and sacubitril/valsartan
53:33 Vocal cord dysfunction
56:50 Response from Stuart and Paul
62:20 Outro

Links from the show:

1. Paul’s picks: Charly Bliss, Baroness (heavy metal), Royal Blood
2. GOMER Blog
3. How Walking in Nature Changes Your Brain NYTIMES 2015
4. Being Mortal (book) by Atul Gawande
5. Cellulitis A Review JAMA 2016
6. Weng QY, Raff AB, Cohen JM, Gunasekera N, Okhovat J, Vedak P, Joyce C, Kroshinsky D, Mostaghimi A. Costs and Consequences Associated With Misdiagnosed Lower Extremity Cellulitis. JAMA Dermatol. 2017;153(2):141-146. doi:10.1001/jamadermatol.2016.3816
7. AGEP synopsis from dermnetnz.com
8. DRESS/DIHS synopsis from dermnetnz.com
9. Abrupt vs gradual tobacco cessation Ann Transl Med 2016
10. Review of a parace (Acetaminophen) for acute low back pain Cochrane 2015
11. Naproxen versus naproxen plus SMR or Opioids for back pain JAMA 2015
12. ACP guidelines low back pain Annals of Internal Medicine 2017
13. Transdermal estrogen not associated with increased risk for stroke Climacteric 2010
14. Micronized progesterone not associated with increased risk for stroke Climacteric 2012
15. Oral iron supplements increase hepcidin and decrease iron absorption from daily or twice-daily doses in iron-depleted young women. Blood 2015
16. Intermittent oral iron supplementation during pregnancy. Cochrane 2015
17. Weekly iron and folate and twice yearly albendazole for prevention iron deficiency Vietnam. PLOS 2017
18. KDIGO Clinical Practice Guidelines for anemia of chronic kidney disease. Aug 2012.
19. Angiotensin–Neprilysin Inhibition versus Enalapril in Heart Failure (PARADIGM-HF). NEJM 2014