#93: Clinical Pearls ACP 2018 with Nina Mingioni MD

April 30, 2018 | By Matthew Watto, MD

A fast moving recap of hot topics and clinical pearls live from Internal Medicine’s largest national conference, ACP 2018 in New Orleans! Dr. Nina Mingioni, Clinical Associate Professor and director of Undergraduate Medical Education in Internal Medicine at Thomas Jefferson University Hospital serves up some knowledge food for our brain holes. Topics: the athlete as a patient, sports physicals, food as medicine, medical marijuana (cannabis), and more! Listeners, please let us know what you liked, didn’t like and how we could make this better. YouTube video of this episode available here:ACP 2018 Recap with Nina Mingioni.

Written by: Nina Mingioni MD, Hannah Abrams. Producer/videographer: Chris Chiu MD. Hosts: Matthew Watto MD, Stuart Brigham MD, Paul Williams MD. Editor: Matthew Watto MD

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Clinical Pearls
Dr. Mingioni gave us pearls from 5 lectures that she recapped for the ACP Highlights session:

The Athlete as Patient

• Pre-participation screening: ECG and exercise stress test are NOT recommended in pre-participation screening of competitive athletes (2007 AHA Guidelines Physical Activity). ECG has low specificity in the athletic population due to adaptation in a trained athlete’s heart (post by Shippon et al on acc.org October 2015).

• Do middle-aged patients need a CV exam before high intensity training?: Three of 785 patients in this study who needed exclusion from activity were identified by resting EKG, not a fancy test (Menafoglio Br J Sports Med 2015)
• RED-S: “Female Athlete Triad” has been renamed Relative Energy Deficiency in Sport (RED-S) by the IOC. RED-S includes metabolic, bone, menstrual, immune, cardiovascular, and psychological complications and affects both women and men (IOC Consensus Statement Br J Sports Med 2014).

Most Important Adverse Drug Reactions 2018

• Warfarin: Trimethoprim-sulfamethoxazole causes a mean INR increase of 1.76 (Glasheen et al JGIM 2005) and Prednisone causes a mean increase of 1.24 (Hazelwood Ann Pharmacother 2006). Acetaminophen >2 g/day can also significantly increase INR, but less predictably (Review of acetaminophen effect on INR J Pharm Pract 2013).
• SSRIs: Serotonin syndrome highly unlikely when SSRIs are given with triptans (Orlova JAMA 2018).

Food as Medicine

• Dietary counseling: It’s easier to understand counselling about specific foods rather than nutrients. Offer substitutions and help patients set specific goals (speaker’s expert opinion, Dr Michelle McMacken, MD @Veg_MD).

Marijuana: Its Roles, Rewards, and Risks

• “Entourage effect”: The main anti-inflammatory compound in marijuana is cannabidiol (CBD), but other components (terpenoids and flavonoids) may have unstudied medical effects (Russo Br J Pharmacol 2011).

The Human Microbiome in Health and Disease

• Keeping up with research: This basic science lecture for the ACP presented the latest evidence on the microbiome (Review by V. Young Clin Microbiol Infec 2017). The state of research right now is evolving from association to causation studies (speaker: Dr Vincent Young MD, PhD @a2binny).
• Gumbo is probably atherogenic: One example of microbiome research showed that the gut flora directly metabolizes phosphatidylcholine (in cell membranes)  into an atherogenic substance (Nowinski. Nutrition 2018) . This is another piece of evidence to support the Food in Medicine lecture’s conclusion:

Time stamps:

• 00:00 Music and disclaimer
• 02:48 Getting to know our guest
• 06:07 The athlete as a patient
• 10:20 Relative energy deficiency in sports
• 12:00 Drug interactions
• 15:51 Food as medicine
• 21:56 Marijuana
• 30:24 Outro