#94: Random Pearls: Microbiome, POTS, Gabapentin, and Leonardo Da Vinci

May 7, 2018 | By Matthew Watto, MD

A random serving of knowledge food for your brain hole with returning guest, Dr. Alan Dow, Professor of Internal Medicine at Virginia Commonwealth University School of Medicine. Our final live recap show from ACP 2018 covering: human microbiome, copper deficiency, POTS syndrome, substances of abuse, drugs for delirium and how to be more like Leonardo Da Vinci. Please let us know what you liked, didn’t like and how we can make the show better.

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Advice
“Don’t be afraid to use your talents to tackle the problems you see before you” -Alan Dow, MD
“Writing is easy. You just open up a vein and bleed.” –Ernest Hemingway

Random Pearls
Dr. Dow gave us pearls from 5 lectures that he attended at ACP

The Human Microbiome

• Fecal Matter Transplant Update: Microbiome research shows that people who get C. Diff have less heterogeneous microbiomes (JC Lagier Hum Microbiome J 2016). Next steps are to show how the microbiome relates to other clinical outcomes and tease out causality vs. association.
• https://twitter.com/thecurbsiders/status/987716716632428546

Thieves’ Market

• A Unique Case: The market is a diagnostic case presentation format where people can shout out differential diagnoses as pieces of the case are presented. Patient presented with neuropathy with megaloblastic anemia from copper deficiency induced by zinc toxicity from denture cream. Here’s a case report of zinc-induced copper deficiency, from zinc supplements (J Johnsrud. Perm J 2017)

The Orthostatic Outpatient

• Postural Orthostatic Tachycardia Syndrome: POTS physiology is similar to that of astronauts’: the left ventricle atrophies about 1% per day such that stroke volume decreases. When the heart has to work against gravity (standing), it must increase heart rate to maintain the same cardiac output.
• A new name for POTS?! In POTS, the heart is “too small” and might be more aptly named “the Grinch syndrome” (Fu Q et al. JACC 2011)
  https://twitter.com/thecurbsiders/status/987718375752323072

Multiple Small Feedings of the Mind: Substance Use Disorder and Psychiatry

• Benzodiazepines in Delirium: Non-pharmacologic therapy is still first line for delirium. Multiple trials for delirium use benzodiazepines as the ‘rescue medication’ for agitation. Risk of paradoxical reaction to benzodiazepines seems to be rare, <1%. (CE Mancuso. Pharmacotherapy 2012). A Cochrane review on use of benzos for delirium is pending (Jin YH et al. Cochrane DB of Reviews 2017).
• https://twitter.com/thecurbsiders/status/987719964210712576
• https://twitter.com/thecurbsiders/status/987718915223642113

PechaKucha

• Presentation Format: PechaKucha is a presentation format in which presenters present 20 slides each for 20 seconds each, with no pauses or going backward.
• Da Vinci: Dr. Sal Mangione’s PechaKucha compared Leonardo da Vinci and the character traits that allowed him to be excellent to the modern physician – Watch here, but not for free : (
• https://twitter.com/thecurbsiders/status/987721011939414017

Time stamps:

• 00:00 Disclaimer
• 01:30 Guest bio
• 03:19 Getting to know our guest, podcast, and book recommendations
• 08:55 Human microbiome
• 11:05 A case of anemia and neuropathy
• 13:30 Physiology and treatment of POTS syndrome
• 17:00 Novel substances of abuse
• 20:17 Benzodiazepines for delirium
• 24:00 Leonardo Da Vinci versus the modern physician
• 27:18 Outro

Links from the show:

1. Ezra Klein (podcast)
2. Slow Burn: A podcast about Watergate.
3. Eveningland: Stories (book) by Michael Knight
4. The Flaming Lips – tour schedule
5. Tim Ferriss (podcast) episode with Astro Teller of Google X
6. Gut microbiota and Cdiff infections by JC Lagier. Human Microbiome J Dec 2016.
7. Salt and the microbiome (paper) from Nature by Wilck, N et al. Nature volume 551, pages 585–589 (30 November 2017) doi:10.1038/nature24628
8. Cardiac Origins of POTS, Grinch Syndrome by Q Fu et al. JACC 2011
9. Standing up to POTS (Dr Levine’s exercise protocol)
10. Exercise program to improve activity in POTS by Richardson MV et al Physiother Theory Pract. 2017 Aug;33(8):670-679. doi: 10.1080/09593985.2017.1328719. Epub 2017 Jun 7.
11. Video call from family helps mitigate delirium by Waszynski CM et al. Int J Nurs Stud. 2018 Jan;77:154-161. doi: 10.1016/j.ijnurstu.2017.09.018. Epub 2017 Oct 7.
12. PechaKucha from ACP 2018 Watch here, but not for free : (