#22: Best of 2016 Recap and Recommendations

January 2, 2017 | By Matthew Watto, MD

Consolidate your knowledge and reinforce the learning you’ve done with us in 2016. Enjoy this holiday helping of knowledge food for your brain hole. The guys offer their best of recommendations for 2016 and recap key teaching points from the past year so you have the tools to dominate 2017.

Recommend a guest or topic and give feedback at thecurbsiders@gmail.com 

Clinical Pearls:

SPRINT trial debate

1. Bias effects results seen in this trial. e.g. stopped early
2. Blood pressure (BP) control may have been overestimated based on how BP was measured leading to increased CV events (Stuart’s view).
3. BP measurements in trial likely reflected out of office BP so results are useful (Paul’s view).
4. Lower BP is probably safe, even in the elderly so be reluctant to back off on meds.

HTN Urgency

1. Verify BP reading and measurement technique
2. Evaluate for pain, anxiety, volume overload, nonadherence, or noncompliance
3. Treat high BP with long term goals in mind (i.e. go up on chronic/long-acting meds)

Anticoagulation

1. Avoid warfarin in patients with gastric bypass or Crohn’s with ileitis.
2. Use SPARC tool to visually demonstrate risks and benefits of anticoagulation in Afib.
3. Physicians commonly underestimate benefit of anticoagulation in older sicker patients and overestimate risk of bleeding.

Fibromyalgia and chronic pain

1. Recognize the constellation of fatigue, memory problems, sleep disturbance, and multifocal pain as fibromyalgia.
2. Use the 2011 American College of Rheumatology criteria for diagnosis. No tender point exam required!
3. Nonpharmacologic therapies and education are most effective (see video links below).
4. Chronic painful conditions like rheumatoid arthritis, or lupus can lead to fibromyalgia.

Functional Medicine

1. At least 80% of your food should be whole foods.
2. Use the Dirty Dozen and Clean 15 to guide organic food choices.
3. Knowledge of pathophysiology and biochemistry can be used to treat disease e.g. treating small intestinal bacterial overgrowth can fix iron deficiency and indirectly treat iron deficiency.

Lipids

1. Lowering LDL is key. Some statin is better than none, so consider intermittent dosing (three times weekly) of atorvastatin or rosuvastatin.
2. Statins have a 20 year safety record, are cheap, and will remain king for now.
3. Check baseline LDL and monitor percent decrease on statin therapy to ensure desired effect (e.g. 50% drop in LDL for patient requiring high intensity).
4. Withdrawal of statins at end of life is warranted and safe.

Insomnia

1. Nonpharmacologic therapy is as good or better than pharmacologic therapy.
2. Benefits of nonpharmacologic therapy persist 1-2 years after discontinuation.
3. Identify problem with sleep initiation versus maintenance, or both, then choose agent.
4. Use long taper of sleep agent (several months) along with CBT for nightly problems with sleep.
5. Intermittent dosing of sleep agent okay if only intermittent sleep trouble.

Osteoporosis

1. If secondary hyperparathyroidism present, then target normal PTH not just a Vit D level 30-50 ng/ml.
2. After hip fracture, first normalize Vit D and/or PTH, then treat with bone conserving agent.
3. Drug holiday stops when bone density falls, fracture occurs, or risk increases (e.g. steroid use).
4. Patients may require multiple courses of bisphosphonates or other bone conserving drugs.

In-flight emergencies

1. Know contents of standard medical kit include:
2. Be prepared to improvise.

Lessons learned

1. Failure is essential to learning and improving.
2. Don’t fall victim to “fear of being left out”. Saying “No” protects you from being spread thin.
3. Overcome the “curse of knowledge” by teaching the basics and gearing lesson to level of learner.

Disclosures:
The Curbsiders report no relevant financial disclosures, but hope to have a long list of them in the future.

Time Stamps

00:00 Intro

02:54 Best of 2016 Articles

07:45 Best of 2016 Book recommendations

12:44 Best of 2016 Apps

15:49 SPRINT trial

24:34 Hypertensive urgency

27:05 Anticoagulation

33:00 Fibromyalgia and chronic pain

38:38 Functional Medicine

42:05 Lipids

48:09 Insomnia

52:13 Osteoporosis

56:29 In-flight emergencies

59:09 Lessons learned in 2016

1:03:45 Outro

Links from the show:

Articles

1. Blood pressure as a risk factor for headache and migraine: a prospective population-based study.  Eur J Neurol. 2015 Jan;22(1):156-62, e10-1. doi: 10.1111/ene.12547. Epub 2014 Aug 25.
2. Imbalanced insulin action in chronic overnutrition: Clinical harm, molecular mechanisms, and a way forward. Atherosclerosis. 2016 Apr;247:225-82
3. Sniffing out significant “Pee values”: genome wide association study of asparagus anosmia http://www.bmj.com/content/355/bmj.i6071

Books

1. How Doctors Think by Jerome Groupman
2. Multipliers: How the Best Leaders Make Everyone Smarter by Liz Wiseman:
3. Spook Country by William Gibson
4. Carter Beats the Devil by Glen David Gold
5. Evidence Based Physical Diagnosis by Steven McGee

Apps

1. Download Google Drive
2. UptoDate
3. My Fitness Pal
4. Map My Run

Other links

1. SPARC Tool for anticoagulation in atrial fibrillation
2. Warfarin use in heart failure patients may have a mortality benefit
3. Fibroguide.com
4. Chronic Pain is it all in their head
5. Five minute video on Chronic Pain from Australia (not the VA!)
6. EWG.org (environmental work group) – gives the Dirty Dozen and the Clean 15

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