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The Curbsiders Internal Medicine Podcast | MedEd | FOAMed | Internist | Hospitalist | Primary Care | Family Medicine

Supercharge your learning and enhance your practice with this Internal Medicine Podcast featuring board certified Internists as they interview national and international experts to bring you clinical pearls and practice changing knowledge. Doctors Matthew Watto, Stuart Brigham, and Paul Williams deliver some knowledge food for your brain hole. No boring lectures here, just high value content and a healthy dose of humor. Fantastic podcast for Internal Medicine, Family Medicine, Primary Care, and Hospital Medicine. Topics include heart disease, obesity, diabetes, cardiac imaging, migraines, fibromyalgia, hypertension, cholesterol, osteoporosis, insomnia, testosterone, functional medicine, dementia, and more!
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Now displaying: 2016

Supercharge your learning and enhance your practice with this Internal Medicine Podcast featuring board certified Internists as they interview national and international experts to bring you clinical pearls and practice changing knowledge. Doctors Matthew Watto, Stuart Brigham, and Paul Williams deliver some knowledge food for your brain hole.

thecurbsiders@gmail.com

Dec 19, 2016

Summary:

Advance your career and expertly navigate the job hunt with guidance from Dr. Alia Chisty of Temple University Hospital.  Highlights include Dr. Chisty offering up her personal email address for mentorship and Dr. Watto announcing our first contest. This episode is full of wisdom to enhance your career whether you're gainfully employed or looking for your first job.

Clinical Pearls:

  1. Meet with your mentors at the start of the process. They can:
    1. Help clarify your goals
    2. Activate your network
  2. Look for jobs 9 months in advance.
  3. An ideal job: incorporates your interests, skills, and values.
  4. Leverage your network (friends, mentors, program director) to identify available opportunities
  5. Email your cover letter (typically an email) and CV to the division chair or section chief
    1. Craft your elevator pitch.
    2. Do your homework.
    3. Explain how you will add value.
  6. When interviewing:
  7. Give yourself credit! Highlight experiences in your CV (e.g. conference attendance, lectures given, etc.)
  8. Have someone review and proofread your CV.
  9. If an employer makes a promise, then have it included in your contract. Don’t just take their word!
  10. Have a lawyer review your contract.

Goal: Listeners will learn to craft a systematized approach to finding their perfect job.

Learning objectives:

By the end of this podcast listeners will:

  1. Recognize timeline for applications and finding or switching jobs.
  2. Design an effective CV and cover letter.
  3. Recognize the importance and utility of mentors in the application process

Disclosures:

Dr. Chisty reports no relevant financial disclosures.

Time Stamps

0:20 Intro

03:40 Rapid fire questions

07:10 When to start looking for jobs

09:22 How to narrow your focus

11:33 Too many choices may be worse

13:05 Asking yourself the right questions

14:40 Quick recap of what we’ve learned

15:20 Who to contact, and what to send

19:30 Recruiters

22:25 How to prepare for your interview

26:05 Ramit Sethi on finding your dream job and negotiating your salary

27:36 Where to look for jobs (including social media)

31:10 Discussion of social media

33:18 What to include in your CV

35:25 Our first contest (send us your CV!)

36:30 So you’ve been offered a job (s)

38:38 Take home points

40:15 Outro

Links from the show:

  1. NEJM career center: http://www.nejmcareercenter.org/jobs/internal-medicine/
  2. JAMA career source: http://www.jamacareercenter.com/resources_overview.cfm
  3. Zerzan, J.T. et al.  2009.  Making the most of mentors: a guide for mentees.  Academic Medicine 84: 140-144. https://www.ncbi.nlm.nih.gov/pubmed/19116494
  4. Ramit Sethi on finding your dream job http://www.iwillteachyoutoberich.com/find-your-dream-job/
  5. Ramit Sethi on negotiating your salary http://www.iwillteachyoutoberich.com/blog/salary-negotiation/
  6. Pride and Prejudice by Jane Austen
  7. Harry Potter and the Goblet of Fire by JK Rowling
  8. NEJM Journal Watch http://www.jwatch.org
  9. AHRQ ePSS app  https://itunes.apple.com/us/app/ahrq-epss/id311852560?mt=8

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Dec 5, 2016

Summary:

On this episode we’ll teach you to dominate hypertensive urgency and severe hypertension (HTN) in the clinic, the ER, or on the hospital wards. The Curbsiders offer you this delicious serving of knowledge food so you can manage high blood pressure (BP) without making the same egregious errors that we made during our more formative years.

Of note, The Curbsiders are guestless for this episode. Guestless? Is that a word? Our guest for this episode was supposed to be Dr. Wallace Johnson, a Cardiologist, and expert on HTN from the University of Maryland. He did a fantastic job, but, unfortunately, technical difficulties caused us to lose any useable audio. Our sincerest gratitude and deepest apologies to Dr. Johnson. Nevertheless, we pressed on and used one of our own, the illustrious Dr. Paul Williams, as our expert guest.

Clinical Pearls:

  1. Hypertensive crisis is divided into hypertensive emergency and hypertensive urgency.
    • “Emergency” needs IV therapy NOW
    • “Urgency” needs increased oral therapy over next 24-72 hours
  2. History, physical exam, and familiarity with the patient are key for triage (e.g. verify BP readings, assess compliance, etc.)
  3. Severe HTN and hypertensive urgency can often be treated in the outpatient setting
  4. IV agents are not indicated outside of true hypertensive emergency (i.e. objective end organ damage)
  5. We recommend increasing dose or frequency of existing BP meds as 1st line (better long-term solution)
  6. Intermittent dosing of oral labetalol, clonidine, and captopril can be considered as 2nd line (short-term solution)
  7. Rule out uncontrolled pain, volume overload, alcohol withdrawal, illicit drug, and missed medications as cause of severe HTN
  8. Evidence from observational studies suggests that headaches are NOT caused by HTN
  9. Untreated severe HTN was historically fatal in months to years prior to development of antihypertensives

Goal: Listeners will become proficient in the appraisal of severe hypertension/ hypertensive urgency and employ safe and practical management strategies.

Learning objectives:

By the end of this podcast listeners will:

  1. Confidently triage patients with severe hypertension and provide appropriate disposition in a variety of settings
  2. Employ a safe and common sense approach to the treatment of severe hypertension in the clinic, the ER, or on the wards
  3. Be familiar with pharmacologic management of severe hypertension in a variety of settings
  4. Recognize the common causes of severe blood pressure elevation in the inpatient setting
  5. Counsel patients on the relationship of severe hypertension and headache
  6. Recall the natural history of untreated severe hypertension

Disclosures:

The Curbsiders report no relevant financial disclosures, but hope to become successful enough to display an absurd list of disclosures in the future.

Time Stamps

0:00 Hook

0:26 Intro

1:38 Rapid fire questions

03:45 Triage of patient with severe HTN

05:05 Case example HTN in office

07:05 Does HTN cause a headache?

08:30 Workup of severe HTN in the office

10:20 Stuart discusses HTN and headaches

11:30 In office treatment of blood pressure

14:28 Recap

15:50 Stuart discuss HTN emergency at normal BP

17:00 Acute treatment of HTN in ER

18:10 Approach to the inpatient with HTN

20:50 Choice of agent for inpatient HTN

23:23 Italian study of HTN crisis in the ER

24:20 Outcomes in asymptomatic patients with severe HTN

26:15 Sleep apnea and HTN

27:10 Natural history of untreated severe HTN

29:10 Take home points

30:50 Outro

Links from the show:

  1. Blood Meridian by Cormack McCarthy
  2. Horton Hears a Who by Dr. Seuss
  3. ASCVD risk calculator http://tools.acc.org/ASCVD-Risk-Estimator/
  4. Epocrates. Download it here
  5. Dr. Johnson’s excellent review article on hypertensive crisis https://www.ncbi.nlm.nih.gov/pubmed/23102030
  6. Another great review with tables on oral drug therapy and dosing for hypertensive crisis https://www.ncbi.nlm.nih.gov/pubmed/18710665
  7. Fascinating article from 1928 on The Syndrome of Malignant Hypertension* http://archinte.jamanetwork.com/article.aspx?articleid=535650
  8. Observational study from Italy characterizing symptoms and outcomes in hypertensive crisis https://www.ncbi.nlm.nih.gov/pubmed/8591878
  9. JNC 7 recommendations for hypertensive crisis: See page 54 of this PDF for details http://www.nhlbi.nih.gov/files/docs/guidelines/express.pdf
  10. Most recent review we could find on hypertensive crisis https://www.ncbi.nlm.nih.gov/pubmed/25575271
  11. Migraine and subsequent risk of stroke in the Physicians' Health Study. https://www.ncbi.nlm.nih.gov/pubmed/7848119
  12. Blood pressure as a risk factor for headache and migraine: a prospective population-based study. https://www.ncbi.nlm.nih.gov/pubmed/25155744
  13. Blood pressure and risk of headache: a prospective study of 22,685 adults in Norway. https://www.ncbi.nlm.nih.gov/pubmed/11909904
Nov 21, 2016

Summary:

Does the thought of responding to an in-flight emergency ruin your air travel? Then tune in because on this episode, Angelica Zen, MD, Chief Resident of Internal Medicine at UCLA, recounts a harrowing tale of heroism at 30,000 feet and schools us on how to throw down in an in-flight emergency. We review what’s available in the standard medical kit, common conditions encountered, and the medical legal implications of responding to in-flight emergencies. This episode is a must listen before you next step on a plane.  

Clinical Pearls:

  1. Stay Calm!  If you freak out, so will everyone else.
  2. Think outside the box and be prepared to improvise from available resources. (e.g. ask another passenger for a glucometer)
  3. Standard medical kit contains - manual BP cuff, stethoscope (cheap), gloves, oropharyngeal airways, CPR masks, bag-valve masks, IV set, 500 ml saline, needles, syringes, analgesic tabs, antihistamine (tabs or injection), aspirin, atropine, inhaler (bronchodilator), Dextrose 50%, Epi (1:1000 and 1:10000), IV lidocaine, nitroglycerin tabs, supplemental oxygen.
  4. Don’t forget to utilize the ground medical team!
  5. Legal repercussions very unlikely unless there is “gross neglect” or “intentional harm”. DON’T treat patients if YOU’VE BEEN DRINKING!
  6. Common emergencies in order of decreasing frequency - syncope and presyncope, dyspnea, acute coronary syndrome, altered mental status, psychiatric emergencies, stroke, cardiac arrest

Goal: Listeners will understand their role and potential liabilities during in-flight emergencies and effectively utilize available resources for triage, patient care, and decisions about diverting the plane.

Learning objectives:

By the end of this podcast listeners will:

  1. Be familiar with the contents of the standard medical kit
  2. Think outside the box to identify, improvise and utilize available resources for patient care
  3. Recognize the medical legal consequences of providing emergency medical care on a plane
  4. Confidently evaluate and manage common in-flight emergencies using the available resources

Disclosures:

Dr. Zen reports no relevant financial disclosures.

Time Stamps

00:26 Intro

02:06 Start of Interview

03:02 Rapid Fire Questions

07:08 Dr. Zen tells her story

17:27 Monitoring your patient in-flight

18:05 Contents of the standard in-flight medical kit

20:10 What Dr. Zen would have done differently

21:05 How to use available resources in-flight

22:20 Medical legal implications

26:07 How to respond to common in-flight emergencies and how to respond

27:35 Syncope and presyncope

29:52 Hypoxia altitude simulation test (HAST)

31:15 Altered mental status

31:52 Anaphylaxis

33:19 Stroke and acute coronary syndrome

34:51 Dr. Zen’s take home points

36:40 Outro

Links from the show:

  1. Baby delivered in-flight by Angelica Zen, MD http://newsroom.ucla.edu/stories/
  2. Pharmacy article detailing supplies in standard medical kit on plane http://www.ashp.org/menu/News/PharmacyNews/NewsArticle
  3. Great review article on In-Flight Emergencies. Nable JV, Tupe CL, Gehle BD, Brady WJ.  In-Flight Medical Emergencies during Commercial Travel. N Engl J Med. 2015 Sep 3;373(10):939-45. doi: 10.1056/NEJMra1409213.
  4. Article on the hypoxia (or high) altitude simulation test (HAST) https://www.ncbi.nlm.nih.gov/pubmed/18398121
  5. Interesting article: Passenger safely defibrillated 21 times during International Flight. Harve H1, Hämäläinen O, Kurola J, Silfvast T. AED use in a passenger during a long-haul flight: repeated defibrillation with a successful outcome. Aviat Space Environ Med. 2009 Apr;80(4):405-8.
  6. How Doctors Think by Jerome Groupman: Amazon.com link
  7. NEJM Physicians First Watch http://www.jwatch.org/medical-news
Nov 7, 2016

Summary:

On this episode, we got served! Endocrinologist, Dr. Pauline Camacho, current president of AACE and Professor of Medicine at Loyola University Chicago makes it rain clinical pearls as she schools us on the use of calcium, Vitamin D, bisphosphonate therapy and drug holidays. This is a must listen for anyone treating osteoporosis. Make sure to check out the new 2016 AACE guidelines, which include infographics for patients and their easy to use algorithm.

Clinical Pearls:

Vitamin D

  1. Vitamin D for postmenopausal osteoporosis prevention (women ≥ 50 yo)
    1. Optimum Vit D level between 30-50 ng/ml recommend
    2. Check PTH if Vit D is very low
    3. If secondary hyperparathyroidism then treat until PTH normalizes
    4. Usual dose is Vit D2 or D3 1000 to 2000 IU daily
    1. Weekly dosing may be required for loading
    2. Vit D3 preferred if malabsorption (e.g. post gastric bypass)
  2. Vitamin D2 or D3 50,000 IU dosed monthly or biweekly is probably safe despite trials suggesting increased falls2-3

Calcium

  1. Calcium recommended total daily intake through diet +/- supplements
    1. postmenopausal women 1200 mg daily
    2. Men 1000 mg
  2. Calcium citrate has better absorption, especially in the elderly or those on PPI

Osteoporosis and drug therapy

  1. AACE’s four criteria for diagnosis osteoporosis
    1. T-score –2.5 or below in the lumbar spine, femoral neck, total, and/or 33% (one-third) radius
    2. Low-trauma spine or hip fracture (regardless of BMD)
    3. Osteopenia or low bone mass (T-score between –1 and –2.5) with a fragility fracture of proximal humerus, pelvis, or possibly distal forearm
    4. Low bone mass or osteopenia and high FRAX® fracture probability based on country-speci c thresholds
  2. Bisphosphonate therapy
    1. Treat for 5-10 years with oral or 3-6 years with IV bisphosphonates
    2. High fracture risk: elderly patients or those with hx of fracture then consider IV agents 1st line (zoledronic acid, denosumab, teriparatide)
  3. Therapy is successful if:
    1. Stable bone mineral density (BMD)
    2. Increasing BMD
    3. Diminishing levels bone turnover markers (e.g. N-terminal and C-terminal cross-linked telopeptides)4
  4. Therapy is a failure if:
    1. Significant or progressive loss of BMD (using a reliable machine)
    2. Fracture occurs
  5. Drug holiday may last several years, but ends if:
    1. Fracture occurs
    2. BMD declines significantly
    3. Rising bone turnover markers (telopeptides)
  6. After drug holiday the clock resets. Meaning patient may start another full treatment course with bisphosphonate, denosumab or teriparatide
  7. After a hip fracture
    1. Check Vit D level and replete
    2. Start bisphosphonate once Vit D level corrected (usually takes 2-3 months)
  8. Routine testing of BMD is recommended for men >70 yo
    1. If you can get it covered!

Disclosures:

Dr. Camacho did not report any relevant financial disclosures.

Learning objectives:

By the end of this podcast listeners will be able to:

  1. Make recommendations for daily intake of vitamin D, recognize appropriate levels, and treat secondary hyperparathyroidism
  2. Ensure adequate calcium intake through diet and/or supplementation and counsel patients on risks and benefits
  3. Select appropriate bone preserving therapy, treatment course, and learn to monitor for treatment failure
  4. Identify appropriate timing of drug holidays and reinitiation of drug therapy 

Links from the show:

  1. Hot off the press! 2016 AACE Guidelines for postmenopausal osteoporosis https://www.aace.com/files/final-appendix-sept-7.pdf
  2. Monthly High-Dose Vitamin D Treatment for the Prevention of Functional Decline RCT JAMA Int Med Jan 2016
  3. Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women JAMA 2010
  4. Eastell R et al. Bone turnover markers and bone mineral density response with risedronate therapy: relationship with fracture risk and patient adherence. J Bone Miner Res. 2011 Jul;26(7):1662-9. doi: 10.1002/jbmr.342. 

Further recommended reading:

  1. Calcium intake and bone mineral density: systematic review and meta-analysis
  2. Calcium intake and risk of fracture: systematic review
  3. Dr. Camacho responds to reader response about physiologic norm for Vit D level http://ajcn.nutrition.org/content/101/2/413.2.full.pdf
  4. Dr. Camacho’s review article on prediction of fracture risk from Jul 2015 https://www.ncbi.nlm.nih.gov/pubmed/26236988
  5. Differing Vit D levels by latitude challenge idea of a physiologic norm https://www.ncbi.nlm.nih.gov/pubmed/25008852
  6. VITAL Study for Vit D and Omega 3 fatty acids for prevention of cancer, heart attack and stroke http://www.vitalstudy.org
 
 
 
 
 
 
 
Oct 31, 2016

 

Summary:

Dr. Robert Centor’s Knowledge Food, Part 2!  On this episode of The Curbsiders, we continue our discussion with the legendary Dr. Centor, focusing on pharyngitis and the highly entertaining origin of the Centor Criteria.  Not only do we learn how to dominate pharyngitis, but we also uncover one of Dr. Watto’s knowledge deficits - Lemierre’s Syndrome.  (He owes us a two minute talk on Lemierre’s Syndrome in case you’re wondering. I know I am.)

Clinical Pearls:

  1. Admit your own limitations!  Many overestimate their skills as a clinical educator.
    1. Preadolescents get streptococcal pharyngitis (...or it’s nothing).
    2. Adolescents are much more complicated with streptococcus, EBV, CMV, acute HIV, fusobacterium, and multiple other causes.
  2. Important: Separate the causes of pharyngitis in preadolescents and adolescents.
    1. General rule: Sore throats should not cause rigors; if present then admit patient, obtain blood cultures, and start antibiotics.
  3. Do NOT miss a peritonsillar abscess or Lemierre’s Syndrome in acute pharyngitis.
  4. Pharyngitis improves within three to five days.  Failure to improve should prompt a more thorough investigation.
  5. Lemierre’s Syndrome (1 in 70,000 untreated pharyngitis patients) is septic thrombophlebitis of the internal jugular vein.  The treatment is IV antibiotics and NOT anticoagulation.  
  6. Dr. Centor and the IDSA recommends Amoxicillin once daily and, if penicillin allergic, Clindamycin.  The most recent IDSA update recommends a 10-day course of Amoxicillin (50mg/kg up to 1000mg once daily).

Dr. Centor’s “Take-Home” Points:

  1. Adolescents tend to have more complicated pharyngitis
  2. Pharyngitis and rigors?  Admit, obtain cultures, and start antibiotics.
  3. Sore throats don’t get worse and, if they do, you need to rethink the case

Disclosures:

Dr. Centor reports no relevant financial disclosures for this topic.

Learning objectives:

By the end of this podcast listeners will be able to:

  1. Identify the limitations of the Centor Criteria in regards to (a) preadolescents and (b) adolescents, taking special precautions in the adolescent population
  2. Understand which acute pharyngitis patients require a more thorough investigation
  3. Be able to identify Amoxicillin as the treatment of choice for acute bacterial pharyngitis with Clindamycin as the second-line antibiotics choice.

Links from the show:

  1. Check our Dr. Centor’s wonderful blog, at http://www.medrants.com or on twitter https://twitter.com/medrants
  2. Centor’s Criteria (MDCalc) -- http://www.mdcalc.com/modified-centor-score-for-strep-pharyngitis/
  3. IDSA Guidelines on Diagnosis and Management of Group A Streptococcus Pharyngitis - http://cid.oxfordjournals.org/content/early/2012/09/06/cid.cis629.full.pdf+html
  4. Original article using the Centor score for pharyngitis https://www.ncbi.nlm.nih.gov/pubmed/6763125?dopt=abstract
  5. Dr. Centor’s article on fusobacterium Centor RM, et al. The clinical presentation of Fusobacterium-positive and streptococcal-positive pharyngitis in a university health clinic: a cross-sectional study. Ann Intern Med. 2015 Feb 17;162(4):241-7. doi: 10.7326/M14-1305.
Oct 24, 2016

Summary:

Dr. Robert Centor’s Knowledge Food, Part 1.  This Halloween, the “Curse of Knowledge” is REAL!  So you think you can teach? This master clinician educator, known for “Centor’s Criteria,” schools us the most common errors made by medical educators and how to improve learner retention.  While we only scratch the surface, Season 1’s arguably penultimate episode should NOT be missed.  After all, how else are you going to learn about Pretty Pimpin’?  Stay tuned for Part Duex when we briefly review Pharyngitis and Dr. Watto finally learns about Lemierre’s Syndrome!  As always, you’re welcome.

Clinical Pearls:

  1. Don’t fall victim to the “Curse of Knowledge!”  Remember that your students/residents do not know what you know!
  2. Effective rounding should include a healthy mixture of both table-top and bedside rounds.
  3. Feedback should be specific, timely (even immediate!), and focused on improvement.  
  4. Allow the learner to self-evaluate before providing specific feedback and invite all members of the team to provide collaborative feedback.
  5. Always remember that feedback should be positive as well as constructive.
  6. There are multiple courses available to further your own skills as a medical educator
  7. The physician-educator should embody the “servant leader” and prioritize medical education (the “service” you are providing).
  8. Consider blogging to improve your own writing!

Dr. Centor’s “Take-Home” Points:

  1. The “Curse of Knowledge” is real -- never assume the basics are known.
  2. The attending physician should embody service before self.
  3. Dr. Centor’s playlist -- Matt Duncan, Lawrence, Saint Paul and the Broken Bones, Houndmouth, Kurt Vile

Disclosures:

Dr. Centor reports no relevant financial disclosures for this topic.

Learning objectives:

By the end of this podcast listeners will be able to:

  1. Understand the basics concepts that underscore effective feedback (specific, timely, and collaborative)
  2. Identify the tenants that underscore effective rounding
  3. Re-evaluate your own teaching style and consider training seminars to improve your skills as a medical educator

Links from the show:

  1. Dr. Centor’s Blog -- http://www.medrants.com/
  2. Dr. Bradley Sharpe’s profile -- http://profiles.ucsf.edu/bradley.sharpe
  3. Stanford Faculty Development Course -- http://sfdc.stanford.edu/
  4. UCSF Workshop - “Developing Skills in the Art of Effective Feedback” -- http://meded.ucsf.edu/radme/developing-skills-art-effective-feedback
  5. Ten Tips for Receiving Feedback -- http://med-ed-online.net/index.php/meo/article/view/25141
  6. Who should take statins? -- https://www.washingtonpost.com/news/to-your-health/wp/2016/10/04/who-should-take-statins-a-vicious-debate-over-cholesterol-drugs-side-effects/?postshare=1551475707596812&tid=ss_tw
  7. Kurt Vile - “Pretty Pimpin” -- https://www.youtube.com/watch?v=659pppwniXA
  8. 7 Habits of Highly Effective People by Stephen Covey
  9. Made to Stick: Why Some Ideas Survive and Others Die by Chip and Dan Heath
Oct 10, 2016

Summary:

Stop feeling helpless in the face of vague complaints like fatigue, digestive problems, mood swings, inability to lose weight, etc. Learn to treat any chronic disease without writing more prescriptions. Heal yourself and your patients with the power of food. Join us for the return of Functional Medicine physician, Dr. Yousef Elyaman, as he schools us on elimination diets, phytonutrients, liver detoxification, going “paleo” and more. This is a deluxe episode so we’ve included a time key below. You’re welcome.

Clinical Pearls:

  1. Use the 80:20 rule. Try to make 80% of your food paleolithic (unprocessed).
  2. Eliminate the chemicals when possible (processed foods, plastics, cleaning products, cosmetics, etc.)
  3. Workarounds for your budget: home garden and/or frozen foods.
  4. Preserve phytonutrients - Avoid microwaves. Lightly saute or eat veggies raw.
  5. Try an elimination diet for one month then reintroduce foods one at a time.
  6. Assess patient readiness and prescribe diet that fits their degree of commitment.
  7. Basic lab panel to consider: Check homocysteine, zinc, 25OH Vit D, B12, RBC folate, RBC magnesium (use diagnosis of fatigue).
  8. More specialized labs: 
    1. SpectraCell - Micronutrient panel.
    2. NutraEval Plasma by Genova Diagnostics.
    3. Check for MTHR mutation (if off then patient needs methylfolate).

Dr. E's Four steps to healing with food

  1. Ensure a nutritionally dense diet.
  2. Remove bothersome foods.
  3. Replace deficiencies.
  4. Rebalance the system.

Disclosures:

Dr. Elyaman reports no relevant financial disclosures for this topic.

Learning objectives:

By the end of this podcast listeners will be able to:

  1. Appraise the quality of a patient’s diet and identify potential sources of intolerance/food sensitivity
  2. Counsel patients on sustainable dietary changes to remove potentially bothersome foods and chemicals
  3. Perform a basic laboratory evaluation to identify deficiencies
  4. Identify resources for patients and providers to facilitate education and adherence

Show breakdown

0:00 Intro.

02:30 Welcome Dr. Elyaman.

03:15 Stuart bums everyone out with a current event.

04:30 Functional Medicine defined.

07:10 Logistics of educating patients on dietary changes.

11:15 Four steps to healing with food.

15:00 Use food to treat chronic disease.

16:45 Fats and a nutritionally dense diet.

20:00 Alzheimer’s and food.

23:45 Phytonutrients.

27:45 Eating on a budget.

33:40 Genetically modified foods, lectins and autoimmune disease.

40:30 Elimination diets.

46:00 Multiple sclerosis, Milk and casein.

50:00 Autism’s interplay with diet, genes, folate metabolism.

53:00 How to boost liver detoxification.

56:00 The Wahl’s protocol for multiple sclerosis.

58:30 Paleo diet.

1:00:00 Patient adherence.

1:07:35 Testing for and repleting vitamin deficiencies.

1:11:15 Fast food salad and inflammatory markers (Stuart derails the show again).

1:14:30 Dr. E’s Take home points.

 

Links from the show:

  1. The Institute of Functional Medicine's Elimination Diet Plan
  2. Stanford FODMAP Diet Handout
  3. Visit Dr. E's website for Absolute Health
  4. Institute of Functional Medicine website - https://www.functionalmedicine.org
  5. Learn the basics - Intro To Functional Medicine by Dr. David Jones and Sheila Quinn
  6. MSQ questionnaire from Dr. Hyman's website - assess medical symptoms and toxicity
  7. DASS 21 questionnaire - for anxiety, depression, stress
  8. A study of macronutrient type on ApoE levels in ApoE2, E3, E4 genotypes
  9. Video on the “10 Americans” study by the Environmental Working Group - chemicals in cord blood https://youtu.be/0-kc3AIM_LU
  10. EWG.org (environmental work group) - gives the Dirty Dozen and the Clean 15
  11. Gluten free diet removes anti islet cell Ab in a child https://www.ncbi.nlm.nih.gov/pubmed/12434905
  12. Dr. Terry Wahls TED Talk - Diet for Multiple Sclerosis (the Wahls protocol)
  13. The Paleo Diet book can be purchased here
  14. Handful of nuts per day lowers mortality in both of these studies https://www.ncbi.nlm.nih.gov/pubmed/25833976 and https://www.ncbi.nlm.nih.gov/pubmed/26548503
  15. 23 and Me genetic testing
  16. SpectraCell - Micronutrient panel
  17. NutraEval Plasma by Genova Diagnostics
  18. Stuart’s Omron blood pressure cuff




Sep 26, 2016

Learn to treat non cancer pain in the elderly. Managing persistent pain in the elderly can be...painful. On this episode Matt and Paul interview Dr. Marissa Galicia-Castillo, a Professor of Geriatrics from Eastern Virginia Medical School board certified in Internal Medicine, Geriatrics, Hospice/Palliative Medicine. Are we being too stingy with opioid prescriptions? How do you assess and treat pain in patients with advanced dementia? We’ve got your answers.

Clinical Pearls:

  1. Persistent pain in the elderly is underrecognized and undertreated
  2. Nonpharmacologic therapy is still first line (get off the couch!)
  3. Scheduled acetaminophen is a valid first line
  4. Consider low dose oxycodone IR as a second line (assuming NSAIDS contraindicated)
  5. Diversion of medication by family members is a concern and may cause treatment failure
  6. Opiates can be a great tool. Don’t be afraid to use them with careful patient selection.
  7. Follow quality of life and functional status as your end points for pain control.
  8. Pain in cognitively impaired may present as behavior problems. Treat the pain and treat the behavior.

Disclosures:

Dr. Galicia-Castillo reports no relevant financial disclosures.

Learning objectives:

By the end of this podcast listeners will be able to:

  1. Recognize that pain in the elderly is often underrecognized and undertreated.
  2. Recognize the signs and symptoms of pain in patients with cognitive impairment.
  3. Utilize opiates safely and effectively for the management of noncancer pain in the elderly
  4. Formulate a basic therapeutic approach to noncancer pain utilizing nonpharmacologic and pharmacologic therapy 

Links from the show:

  1. Dr. Galicia-Castillo’s article on use of opioids for persistent noncancer pain in older adults

http://www.ccjm.org/current-issue/issue-single-view/opioids-for-persistent-pain-in-older-adults/a136ddc8a922abd74237073a1ab89d4f.html

  1. CDC guidelines on prescribing opioids for chronic pain (#8 discusses criteria for naloxone prescribing)

https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf

  1. World Health Organization Pain Ladder

http://www.geriatricpain.org/Content/Management/Interventions/Documents/WHO%20ladder.pdf

  1. Observational study of Naloxone administration along with opiate prescriptions (NEJM Journal Watch 2016).

http://www.jwatch.org/na41676/2016/07/19/should-naloxone-be-prescribed-patients-taking-opioids

  1. Effect size seen with opiates and tramadol were small in this review, but adverse event rates were high. This is why a trial with monitoring of functional  status is recommended.

http://www.ncbi.nlm.nih.gov/pubmed/21472151

  1. A RCT looking at Tramadol for knee osteoarthritis with underwhelming results.

http://www.ncbi.nlm.nih.gov/pubmed/20215961

  1. EULAR 2016 guidelines for treatment of fibromyalgia

http://ard.bmj.com/content/early/2016/07/04/annrheumdis-2016-209724.abstract

  1. Dr. Clauw’s YouTube Video

Chronic Pain: Is it all in their head?

  1. Dr. Clauw’s University of Michigan website for patient self education on fibromyalgia

Fibroguide.com

 

Sep 12, 2016

Summary:

Fifty four percent of physicians report at least one symptom of burnout. On this episode Dr. Philip Kroth an Internist and Chief of Clinical Informatics from the University of New Mexico schools us on how electronic health records (EHR) relate to burnout and tips to promote physician wellness. Miss this episode and you might get burned...out. I refuse to apologize for that pun. Enjoy!

 

Clinical Pearls:

*Check out the article by Shanafelt below to view breakdown of burnout by specialty.

*24/7 access to EHRs is a double-edged sword. You have to protect your own time.

*Turn off email alerts.

*Limit your screen time when off the clock. Kids are only allowed 1 hour per day!

*Take the EHR training and become a MASTER.

*Keep in mind these four domains related to burnout and try to mitigate your risk.

  1. Health information technology and documentation burden
  2. Stress versus control and support. You need to balance the “seesaw”
  3. Health policy and regulation (e.g. ACOs, MACRA)
  4. Physician culture of endurance (e.g. giving yourself an IV when sick instead of going home)

Disclosures:

None reported.

Links from the Show:

1. Article by Shanafelt finding burnout in 54 percent of physicians.

Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014 Shanafelt, Tait D. et al. Mayo Clinic Proceedings , Volume 90 , Issue 12 , 1600 - 1613

2. Turnover of primary care doctors cost about $250,000 in 1991!

Buchbinder, SB et al. Estimates of Costs of Primary Care Physician Turnover. Am J Manag Care. 1999 Nov;5(11):1431-8.

3. Maslach Burnout Inventory

http://www.mindgarden.com/117-maslach-burnout-inventory

4. Volkswagen stops sending emails in the evening.

http://www.bbc.com/news/technology-16314901

Aug 29, 2016

Do complaints of insomnia stress you out? Well, never fear. In this episode our guest is Dr. Karl Doghramji, Professor of Psychiatry, Neurology and Medicine and the Medical Director of the Sleep Disorders Center at Thomas Jefferson University Hospital in Philadelphia. With his help we deconstruct the “dread pirate” insomnia (as I call it) so you can dominate it in your daily practice.

Disclosures:

Dr. Doghramji reports recent relationships with Merck (stock) and consulting work for Merck, Xenoport, Jazz, Inspire, Teva and Pfizer. He has a current research grant from Inspire.

Clinical Pearls:

*Pathophysiology: Likely biological, neurobehavioral and psychological hyperarousal. Possible genetic component.

*Depression, anxiety or PTSD may be their primary disorder. Many insomniacs unaware of their depression. Need a high index of suspicion.

*Sleep apnea is probably cause in 10-20% of patients who present with insomnia.

*GERD can present with insomnia and night time awakenings as its primary symptom.

*CBT works as well as pharmacotherapy and has lasting potential even 1-2 years after discontinuation of therapy.

*High yield nonpharmacologic therapy: Get up at the same time every morning. Don’t sleep in, even if bedtime or sleep onset was delayed.

*Melatonin: It’s effect depends on time administered (see below). It’s not as safe as you think (insulin resistance, low sperm count)

1. Administer very low dose (under 3 mg) four to five hours prior to bed for delayed sleep phase (usually occurs in teens).

2. Administer higher dose (3-5 mg) one hour before bed for sleep initiation (adults with fragmented sleep).

*Agents for sleep initiation: zaleplon, zolpidem, ramelteon

*Agents for sleep maintenance: zolpidem ER, eszopiclone, doxepin (low dose of 3mg or 6mg), gabapentin (off label)

*Suvorexant (orexin antagonist) treats both sleep initiation and maintenance: Start 10 mg and go up 5 mg every few weeks to max 20 mg daily. Orexins are deficient in narcolepsy. Orexins seem to mediate a switch system between arousal and sleepiness.

*Doxepin, gabapentin and ramelteon have very lose risk for abuse. 

*Off-label use of diphenhydramine for sleep is not recommended ("dirty drug"). Trazodone and mirtazapine also have uncertain benefit.

*Mirtazapine 7.5 mg is the dose for insomnia (more sedating). Lower dose favors histamine receptor.

Links from the Show:

1. This is one possible site for online CBT

https://www.sleepio.com as referenced in this study

2. Melatonin associated with impaired glucose tolerance

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173928/

3. American Academy of Sleep Medicine

4. This site below has easy to understand information on sleep related disorders and links to videos explaining sleep hygiene. You can also download sleep logs, get info.

SleepEducation.org Website

5. Review on use of mindfulness and meditation for insomnia.

http://www.ncbi.nlm.nih.gov/pubmed/26390335

Aug 15, 2016

Summary:

In this episode our guest is Dr. Robert Dickson a Pulmonologist from the University of Michigan who studies the respiratory microbiome. We discuss how the lung microbiome differs in health, chronic illness and acute disease states like pneumonia, sepsis and ARDS. The lung microbiome has the ability to predict frequency of exacerbations and even severity and progression of certain lung diseases. We’ll explore all of this plus Dr. Dickson’s new paper published last month in Nature Microbiology, which had the surprise of finding gut bacteria in the lungs during critical illness. Please enjoy this wide ranging discussion

 

Disclosures:

Dr. Dickson did not report any disclosures.

 

Clinical Pearls

1. The lungs are constantly bombarded by microbes and the largest host to microbe interface in the body where bacteria come within millimeters of the blood stream.

2. The lung microbiome is altered in both acute and chronic diseases

3. The lung microbiome is altered by antibiotics, corticosteroids, PPIs and probably lots of other things we are just beginning to discover.

 

Links from the Show:

Dr. Dickson’s latest article reporting gut bacteria in the lungs during critical illnesses.

Dickson, R et al. Enrichment of the lung microbiome with gut bacteria in sepsis and the acute respiratory distress syndrome. Nature Microbiology 1, Article number: 16113 (2016). doi:10.1038/nmicrobiol.2016.113

 

A link to Dr. Dickson’s podcast discussing the role of microbiome and the care and treatment of critically ill patients.

The role of microbiome: The Lancet Respiratory Medicine: January 2016

 

Dr. Dickson’s recent publication in The Lancet.

Robert Dickson. The microbiome and critical illness. The Lancet. Published Online: 11 December 2015. DOI: http://dx.doi.org/10.1016/S2213-2600(15)00427-0

 

Five clinical pearls on the Pulmonary microbiome

Robert P. Dickson and Gary B. Huffnagle. The Lung Microbiome: New Principles for Respiratory Bacteriology in Health and Disease. PLoS Pathog. 2015 Jul; 11(7): e1004923. Published online 2015 Jul 9. doi:  10.1371/journal.ppat.1004923 PMCID: PMC4497592

 

A comprehensive review of the Pulmonary Microbiome field

Dickson, RJ et al. The Microbiome and the Respiratory Tract. Annu Rev Physiol. 2016;78:481-504. doi: 10.1146/annurev-physiol-021115-105238. Epub 2015 Nov 2.

 

Jul 25, 2016

Summary:

In this episode our guest is Master Lipidologist, Dr. Peter Howard Jones from Baylor College of Medicine and the National Lipid Association. My guest host is Dr. Paul Williams, Clinician Educator extraordinaire from Philadelphia. We explore everything you’ll ever want to know about cholesterol and lipids. Are statins still king when it comes to cholesterol lowering? Should we be rushing to use PCSK9 inhibitors? Should we throw away older drugs like fibrates? Are nonpharmacologic therapies like niacin and fish oil worthwhile? Join us for this extensive conversation.

 

Disclosures:

Dr. Jones is the Chief Science Officer at the National Lipid Association. He has served as a scientific advisor to Merck, Amgen and Sanofi.

 

Learning objectives:

1. Identify each individual's risk for cardiovascular disease and counsel them on benefits of therapy.

2. Learn to lower atherogenic lipids by any means necessary and understand the effects of the common lipid lowering drugs

3. Effectively counsel patients on benefits of lipid lowering drugs to promote patient buy in and adherence.

 

Clinical Pearls

1. Omega 3 fatty acids at 1,000 mg daily or more is useful for prevention of sudden death in post ACS patients.

2. Omega 3 fatty acids at dose of 4,000 mg per day is needed to lower triglycerides. Indicated if TG remain above 500 on first line therapy.

3. Hypertriglyceridemia with level above 500 on optimal statin dose, then consider addition of fibrate and/or omega-3 fatty acids. Uncertain clinical benefit in patient with moderate elevation (200-300) of triglycerides.

4. Statin intolerance can be overcome in most patients using the following methods:

a. Same statin at lower dose

b. Different statin

c. Use of rosuvastatin or atorvastatin 3 times weekly

5. Statins are safe to take for at least 20 years and probably longer (this data is still being collected, but will be available in the future)

6. Withdrawal of statins at the end of life is not harmful and may be beneficial.

 

Links from the Show:

 

Studies that used fibrates for preventions of CV events:

Helsinki Heart Study for primary prevention NEJM 1987

VA HIT Study for secondary prevention NEJM 1999

 

Withdrawal of statins at the end of life

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4618294/

 

Expert Consensus on use of Non-Statin Drugs

http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2016/03/30/11/58/2016-acc-expert-consensus-decision-pathway-on-the-role-of-nonstatin

 

National Lipid Association recommendations for patient-centered management of dyslipidemia

https://www.lipid.org/sites/default/files/Recommendations-Part-1.pdf

 

Recommended websites

National Lipid Association

The Heart.org (Medscape)

Journal of Clinical Lipidology

Jul 8, 2016

Treat C. diff, choose the correct antibiotic regimen, and identify who needs fecal transplant as we “curbside” Gastroenterologist, Dr. Adam Ehrlich from Temple University Hospital. On the show, we cover the ins-and-outs of procuring, preparing and performing transplants as well as future directions in this burgeoning field e.g. IBD, obesity, metabolic syndrome and more.

Take Home Points:

  1. Clostridium difficile infection is the only indication for which FMT is allowed by the FDA without special authorization
  2. FMT is VERY effective in these C difficile patients compared to standard of care (approximately 90% cure vs 30%)
  3. We are just beginning to understand the role of the microbiome in human health, and I anticipate many changes in the years ahead where modifying the microbiome will be used to help treat a number of diseases.

 Links from the Show:

Recommended reading...

NEJM Journal Watch for Gastroenterology - register here

Review on novel uses for fecal transplantation

Rossen NG, et al. Fecal microbiota transplantation as novel therapy in gastroenterology: A systematic review. World J Gastroenterol. 2015 May 7;21(17):5359-71. doi: 10.3748/wjg.v21.i17.5359.

Randomized controlled trial of fresh vs frozen fecal transplantation

Fresh vs Frozen Fecal Microbiota Transplant for C diff Recurrent C difficile infection. JAMA 2016

Review on mechanisms for gut microbiota on metabolic syndromes

Qian LL, et al. Effect of the Gut Microbiota on Obesity and Its Underlying Mechanisms: an Update. Biomed Environ Sci. 2015 Nov;28(11):839-47. doi: 10.3967/bes2015.117.

May 30, 2016

In this episode Dr. Yousef Elyaman from the Institute of Functional Medicine schools us on how the biochemistry and pathophysiology we’ve forgotten from medical school can be used to cure illness. FODMAP diet and Antibiotics to cure restless legs syndrome? Melatonin to treat gastroesophageal reflux disease?  This is just a little taste of the knowledge food served up on this introduction to Functional Medicine.

May 11, 2016

This episode, part 2 of our last episode, is a must listen if you’ve ever felt helpless in the face of fibromyalgia and chronic pain. Keep listening for part 2 of our “curbside” with expert clinician and prominent researcher Dr. Daniel Clauw, from the University of Michigan’s Chronic Pain and Fatigue Research Center. The show is chock full of clinical pearls for the mastery of chronic pain syndromes.

May 4, 2016

This episode, part 1 of 2, is a must listen if you’ve ever felt helpless in the face of fibromyalgia and chronic pain. Listen as we “curbside” expert clinician and prominent researcher Dr. Daniel Clauw, from the University of Michigan’s Chronic Pain and Fatigue Research Center. The show is chock full of clinical pearls for the mastery of chronic pain syndromes.

Apr 20, 2016

In this episode we “curbside” SoCal Cardiologist, Dr. Neel Patel. If you’re like us and confused by the smorgasbord of cardiac imaging and stress testing then this show is a must listen. Whether you’re in the clinic or on call for Internal Medicine, Dr. Patel has your answers on coronary artery calcium scoring, coronary CT scans and all types of stress testing.  

Mar 30, 2016

If headache patients strike fear in your heart, then this is the episode for you. In this episode The Curbsiders interview Internist and Headache Specialist Dr. Glen D. Solomon to deconstruct the topics of migraine and chronic tension type headaches. Dr. Solomon is currently a Professor and Chair of the Department of Internal Medicine at Wright State University and a former director of the Headache Medicine Fellowship at the Cleveland Clinic. Join them as they discuss the approach to diagnosis and management of chronic headaches. 

Mar 15, 2016

In this part 1 of 2 episode on the non-Vitamin K oral anticoagulants, The Curbsiders discuss these novel medications and other changes associated with the updated 2016 CHEST guidelines for anticoagulation. 

Mar 1, 2016

In this interview, Matt speaks with Dr. Paul Williams about the SPRINT Trial of Intensive blood pressure control and how it is likely to change clinical practice. Tony and Stuart discuss their own take-home points from the trial. Discussion of ARBs you've never heard of and the holy grail of blood pressure cuffs ensues.

Tags: assistant, blood, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, hypertension, internal, internist, nurse, medicine, medical, pressure, primary, physician, resident, student

Feb 16, 2016

In this inaugural episode, join the Curbsiders as they tackle the hot topic of male hypogonadism and low testosterone by curbsiding Endocrinologist Dr. Jeff Colburn, a leading clinician and educator in San Antonio, Texas

 

Tags: androgen, andropause, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, hypogonadism, internal, internist, libido, low T, medical, medicine, nurse, primary, physician, resident, student, testosterone

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